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NTSB Report
April 3, 1992 · Beech A33 · N9367Y
Paradise, CA
Overview
Report Status
Probable Cause
Event Type
Accident
Date
April 3, 1992
Injury Outcomes
2 injuries (1 fatality, 1 serious injury)
Location
Paradise, CA
Aircraft
Beech A33
Tail Number
N9367Y
Operator
Desmet Jeffrey G
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
LAX92FA161
The 60 hour student pilot had a total of 25 hours in type, all of which were dual. With his current flight instructor, the student returned to their home base airport to perform a prearranged go-around to finalize their dual period for the evening. After the approach to the runway, the instructor called for the go-around. After the climb was established at about 500 feet AGL, he called for the cowl flaps to be opened, and moments later the engine suddenly and without warning quit. The instructor said that after the engine quit, the student pulled the control yoke all the way back and the aircraft entered a deep stall. The airplane had been modified to accommodate an engine with more horsepower which required the installation of cowl flaps. The FAA approved STC modification drawings required the push-pull control for the cowl flaps to be located to the left of the throttle console on a separate switch panel. The actual location of that control in the accident airplane was found to the right of the throttle below the propeller control and next to
NTSB Probable Cause
THE STUDENT PILOT'S INADVERTENT USE OF THE MIXTURE CONTROL INSTEAD OF THE COWL FLAPS AT A CRITICAL PHASE OF FLIGHT, HIS MISUSE OF THE FLIGHT CONTROLS AFTER THE ENGINE FAILURE AND THE INSTRUCTOR'S INADEQUATE SUPERVISION OF THE STUDENT. CONTRIBUTING FACTORS IN THE ACCIDENT WERE: THE NON STANDARD LOCATION OF THE COWL FLAP PUSH PULL CONTROL, DUE TO AN IMPROPER AIRCRAFT MODIFICATION, THE DARK NIGHT LIGHT CONDITIONS WHICH IMPAIRED THE FLIGHT INSTRUCTORS ABILITY TO MONITOR THE STUDENT COCKPIT CONTROL MANIPULATIONS.
Full Narrative
THE 60 HOUR STUDENT PILOT HAD A TOTAL OF 25 HOURS IN TYPE, ALL OF WHICH WERE DUAL. WITH HIS CURRENT FLIGHT INSTRUCTOR THE STUDENT RETURNED TO THEIR HOME BASE AIRPORT TO PERFORM A PREARRANGED GO-AROUND TO FINALIZE THEIR DUAL PERIOD FOR THE EVENING. AFTER THE APPROACH TO THE RUNWAY, THE INSTRUCTOR CALLED FOR THE GO-AROUND. AFTER THE CLIMB WAS ESTABLISHED AT ABOUT 500 FEET AGL HE CALLED FOR THE COWL FLAPS TO BE OPENED, AND MOMENTS LATER THE ENGINE SUDDENLY AND WITHOUT WARNING QUIT. THE INSTRUCTOR SAID THAT AFTER THE ENGINE QUIT THE STUDENT PULLED THE CONTROL YOKE ALL THE WAY BACK AND THE AIRCRAFT ENTERED A DEEP STALL. THE AIRPLANE HAD BEEN MODIFIED TO ACCOMMODATE AN ENGINE WITH MORE HORSE POWER WHICH REQUIRED THE INSTALLATION OF COWL FLAPS. THE FAA APPROVED STC MODIFICATION DRAWINGS REQUIRED THE PUSH-PULL CONTROL FOR THE COWL FLAPS TO BE LOCATED TO THE LEFT OF THE THROTTLE CONSOLE ON A SEPARATE SWITCH PANEL. THE ACTUAL LOCATION OF THAT CONTROL IN THE ACCIDENT AIRPLANE WAS FOUND TO THE RIGHT OF THE THROTTLE BELOW THE PROPELLER CONTROL AND NEXT TO
Flight
Event TypeAccident
Event Time19:54 PST
Nearest Airport0nm N
Runway0
Flight Plan FiledNone
Aircraft FireGrd
Aircraft ExplosionGrd
Aircraft
AircraftBeech A33
Tail NumberN9367Y
Aircraft CategoryAir
DamageDestroyed
OperatorDesmet Jeffrey G
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsContinental · IO-520-BA · Reciprocating · 285
Seats4
People & Injuries
Injury Summary2 injuries (1 fatality, 1 serious injury)
Fatal1
Serious1
Minor0
Uninjured0
Total2
Crew 1Age 31 · First Class
Conditions
ConditionsVMC
LightDark Night
Wind110°
Visibility7 sm
CeilingNone
Temperature / Dew Point64 F / 0 C
Altimeter29.00 inHg
Weather SourcePILO