On November 14, 2009, about 1615 Pacific standard time, a Beech A36, N17803, collided with terrain during a forced landing near San Gabriel, California. The owner operated the airplane under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. The pilot, the sole occupant, was killed. The airplane was substantially damaged during the accident sequence. Visual meteorological conditions prevailed for the local area flight that departed Brackett Field Airport (POC), La Verne, California, about 1600. The flight was destined for Van Nuys Airport (VNY), Van Nuys, California. No flight plan had been filed.

Witnesses reported hearing the engine at idle power, and observing the airplane on a shallow approach to the railroad tracks, with the landing gear down. The witnesses did not report a fire or smoke coming from the airplane when they observed it during the accident sequence.

According to a responding detective from the Los Angeles County Sheriff's Department – Aero Bureau, the airplane had touched down on railroad tracks, bounced a couple of times, and came to rest about 500 yards beyond the initial point of impact.

A friend of the pilot stated that the purpose of the flight was to move airplanes around. His airplane was at POC, so the accident pilot flew the accident airplane from VNY to Jack Northrop Field/Hawthorne Municipal Airport (HHR), Hawthorne, California. They both flew from HHR to POC to pick up the friend's airplane. The flight from HHR to POC was uneventful. The two pilots departed POC about 1600. The friend arrived back at VNY and awaited the accident pilot. When the accident pilot did not return to VNY, the friend started to call VNY tower personnel, as well as mutual friends, and the business at POC where he had picked up his airplane. The business owner at POC informed him that the news was reporting an airplane crash.


A review of Federal Aviation Administration (FAA) airman records revealed that the 49-year old pilot held a private pilot certificate with ratings for airplane single engine land, single engine sea, and instrument airplane.

The pilot held a third-class medical certificate issued on November 10, 2009. It contained the following limitations: the pilot must have available glasses for near vision, and that it was not valid for any class after November 20, 2010.

No personal flight records were located for the pilot. The National Transportation Safety Board (NTSB) investigator-in-charge (IIC) obtained the aeronautical experience listed in this report from a review of the FAA airmen medical records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. The pilot reported on his last medical application, dated November 10, 2009, that he had a total time of 850 hours with 0 hours logged in the last 6 months.


The airplane was a 1977 Beech A36, serial number E-1031. There were no aircraft logbooks available for review. The NTSB IIC obtained copies of aircraft logbook entries for a return to service completed by Howard Aviation, Inc., La Verne, California. The logbook entries were dated November 6, 2009. Airframe total time was listed as 2,255.32 hours. The entries were for the installation of avionics, the installation of circuit breaker switches, and the removal of the number 2 cylinder spark plugs, and the fuel injector. The circuit breaker switches were replaced to comply with airworthiness directive (AD) 2008-13-17. The spark plugs were cleaned, gapped, tested, and then reinstalled on the cylinder and torqued to specification. The fuel injector was clogged; maintenance personnel cleaned, inspected, and then reinstalled the fuel injector.

The airplane was powered by a Lycoming Engines TIO-540-J2BD, serial number L-6400-61A. The engine total time was listed a 2,255.32 hours.


According to a responding deputy from the Los Angeles County Sheriff's Department Aero Bureau, the first identified point of contact (FIPC) was a ground scar identified adjacent to railroad tracks. The airplane came to rest upright against a concrete wall.

Responding FAA inspectors reported that the majority of the fuselage had been consumed by the post-impact fire. The right wing remained in its normal relative position. The left wing, mid-span, had impacted a light pole. The engine separated at the firewall and came to rest in a parking lot just forward of the concrete wall. The propeller assembly remained attached to the engine at the crankshaft flange.


The County of Los Angeles, Department of Coroner, Los Angeles, California, completed the autopsy. The cause of death was listed as thermal injuries, rapid; manner of death: accident. The FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot.

Analysis of the specimens contained no findings for carbon monoxide, cyanide, volatiles, and tested drugs.


An NTSB investigator, FAA inspector (accident coordinator), and representatives from Hawker Beechcraft and Lycoming Engines examined the airframe and engine at Aircraft Recovery Service, Littlerock, California.

For wreckage transportation purposes the left aileron cable, elevator, and rudder cables were cut. Investigators noted that all associated hardware was secured and in place; the cut cables were the appropriate length. The right aileron cable remained attached at the yoke to the wing. The left wing separated at the fuel tank location, and the tip tank for the right wing had separated. Investigators determined that the landing gear was in the extended position. The instrument panel was consumed by the fire. The fuel selector was determined by investigators to be in the left main tank position; flow continuity was established and a small amount of residual fuel was noted in the associate fuel lines. The airframe manufacturer's representative reported that the flaps were in the retracted setting and the elevator trim was 27 degrees tab down (full deflection), which correlated to nose up trim. There were no identified mechanical anomalies noted during the airframe inspection that would have precluded normal operation.

The engine separated from the fuselage, but remained attached to the engine mount structure and engine cowl. Visual examination revealed no evidence of pre impact mechanical malfunction. The upper left side cowling exhibited localized thermal damage. Investigators placed the left cowl in its normal position just forward of the airplane fuselage. A matching thermal pattern was noted in a small section of the airplane skin just aft of the firewall. Further examination of the engine revealed that the left hand exhaust system transition pipe was detached and the respective V-band clamp was not in place. Investigators located the pipe and V-band among the recovered wreckage debris. The V-band clamp, part number MVT69183-200, LW-12093-5 had separated at the band and showed evidence of corrosion. The pipe exhibited crush damage on the smoke joint end, and the corresponding portion that remained attached at the engine was undamaged.

On May 25, 2006, Lycoming Engines issued Mandatory Service Bulletin 240, Mandatory Parts Replacement at Normal Overhaul and During Repair or Normal Maintenance. It states that all V-band couplings and gaskets be replaced at engine overhaul; there were no airworthiness directives that were applicable to the accident V-band clamp. There were no other mechanical anomalies noted with the engine.

Manual rotation of the crankshaft via the propeller produced thumb compression in proper firing order. Mechanical continuity was established throughout the rotating group, as well as valve train continuity, and the accessory section during manual rotation of the crankshaft. The cylinders were borescoped with no evidence of foreign object ingestion. The valves were intact and undamaged.


The three-bladed constant speed Hartzell propeller, serial number B1466U remained attached at the crankshaft flange. One propeller blade was undamaged, the second blade had some damage near the tip, and the third blade was bent slightly aft with diagonal striations near the tip area. The propeller governor remained attached at its mounting point with the pitch control rod securely attached at the control wheel. The pitch control was set near the course setting (low rpm).

Fuel System Components

The fuel system was compromised due to the separation of the engine during the accident sequence. The fuel injection servo was undamaged and secured to its mounting flange. The throttle/mixture controls were secured and attached at their respective control arms of the servo. The throttle was positioned at the idle stop and the mixture control was beyond the mechanical stop, which the engine representative reported was as a result of the engine separation. The fuel injection servo and induction system were free of obstruction. The fuel injection nozzles remained secured at each cylinder and its respective fuel line remained attached. The fuel pump remained attached to the engine at its mounting pad, and the fuel lines remained secured at their respective fittings.

Ignition System

All of the spark plugs remained secure at each cylinder, and their respective spark plug leads remained attached. The top spark plugs were removed and examined. According to the Champion Aviation check-a-plug chart AV-27, the electrodes displayed coloration consistent with normal operation. The spark plugs in the number two, four, and six cylinders were oil soaked, which was attributed to the engine position at the accident site, and storage of the engine prior to the examination. The ignition harness sustained varying degrees of thermal damage and could not be tested. It remained attached to the single-drive dual magneto and respective spark plug. The magneto remained secured on its mounting pad. Magneto-to-engine timing was established; right was 20 degrees, left was 20 degrees before top dead center of the number 1 cylinder. The engine representative verified that these numbers were within manufacturer's specification. Investigators noted that the magneto had been installed onto the engine 180 degrees opposite of the cap, which disabled the retard points. A witness mark inside the cap where the retard points spring tab had been rubbing was identified. Manual rotation of the magneto produced spark at all plug leads.

V-band Clamp Examination

Two exhaust V-band clamps and a section of exhaust pipe were shipped to the NTSB metallurgical laboratory in Washington, D.C., for further examination (The report is attached to the public docket). A staff metallurgist reported that one clamp had fractured through the strap area, the second clamp was not compromised and the exhaust pipe was intact. The T-bolt installed on the fractured clamp measured approximately 1.875 inches in length, according to the drawing the bolt should have been 3.0 inches for a -5 clamp. The strap portion of the clamp, adjacent to a gap between V shaped clamping segments had fractured. The fracture faces were optically inspected and revealed slant fracturing through the strap consistent with a tensile overstress separation. The staff metallurgist also stated that the fracture intersected areas of thick oxidation partially through the strap.

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