United States of America

The PIC stated he was established on an instrument approach when the left engine fuel pressure dropped to zero and the engine quit. He moved the fuel selector to the right rear fuel tank and the engine started. He continued the approach for about 2 miles when the right engine quit followed by the left engine. He made a forced landing to a sandbar. Examination of the airplane revealed the fuel tanks were not ruptured and the fuel tanks were empty.

The pilot was on approach for landing when the right main landing gear did not indicate that it was down. The pilot made a go-around and remained in left closed traffic performing emergency gear extension procedures with negative results. The pilot departed closed traffic and proceeded offshore to burn off fuel before attempting an emergency landing. A company airplane was dispatched to verify the landing gear position. The pilot started a straight in approach for landing five miles from the airport. The right engine started surging and quit. The left engine started surging one mile from the runway. He switched fuel tanks. The engine started and quit. He made a forced landing straight ahead and collided with runway approach lights about 1/4 mile from the end of the runway. The pilot stated he ran out of fuel.

The flight had departed runway 32, under IFR, from a local reliever airport 35 miles south of the destination, and was cleared to intercept the ILS approach for runway 36R. Instrument meteorological conditions existed with a low scattered cloud layer beneath the 900 foot broken clouds. Visibility was 8 miles. The flight never stabilized on the inbound course and glide slope. After acquiring the runway visually, about 3 miles from the airport, the airplane dove for the runway, subsequently touching down with the landing gear retracted. The left propeller incurred greater damage than the right propeller. The airplane began to go around, pitched up, then entered a steep left, descending turn that continued until impact with the ground.

The airplane departed under visual flight rules (VFR) for a flight over mountainous terrain. It was tracked by radar from the departure area to the accident site. While climbing at the normal rate of climb to 15,400 feet, the airplane abruptly disappeared from radar. The wreckage was located among pine trees and exhibited evidence of a steep flight path angle and damage consistent with a stall/spin event. Investigation revealed no indication of airframe or flight control anomalies, and the powerplant and propeller damage was consistent with engine operation at moderate to high power. Evidence indicated that the airplane was free of airframe ice at impact. Postaccident calculations indicate that the airplane was near the maximum certificated gross weight and aft center of gravity limit. The pilot did not maintain instrument flying currency and reportedly avoided instrument meteorological conditions (IMC). Evidence indicated that the pilot did not use oxygen, as required (when flying above 12,000 feet). Ground observations and satellite and Doppler radar imagery indicated widespread cloudiness over the mountains west of Montrose on the day of the accident. Satellite data showed variable cloud tops higher than the airplane's flight altitude in the vicinity of the accident. The radar plot of the aircraft during the climb above 10,000 feet indicated course changes from the southwest to the northwest, back to the southwest and then a sharp turn to the right just prior to the rapid descent.

While in cruise flight at 9,000 feet MSL, the left engine began to 'run rough and lose power.' The pilot said he interpreted the problem as carburetor icing and applied carburetor heat. With the engine still running rough, the left propeller was feathered and the left engine shut down. Restart attempts were not successful. Unable to maintain altitude, the pilot requested to land at a nearby airport. After descending through IMC weather, the pilot realized that he would not make it to the airport, and executed a forced landing to rough/uneven terrain. Examination of the engines revealed that the alternate air doors were missing on the right and left engine. The hinges for the doors were attached to both carburetors and showed no evidence of distortion or impact damage. The doors were not found at the wreckage site. A missing alternate air door would allow ambient air to enter the carburetor, rendering the carburetor heating system ineffective. According to carburetor icing probability charts, the reported temperature and dew point values would be favorable to the formation of induction system icing.

The pilot reported that the airplane lifted off at 70 knots. After accelerating in ground effect the airplane became 'unstable in the roll axis' so he added power. He reported that the left wing tip contacted the runway approximately 3/4 the way down the runway. The pilot then added additional power at which point the left wing contacted the grass off the left side of the departure end of the runway. The pilot then reduced the power to idle and landed the airplane in the grass collapsing the landing gear. The pilot reported that the engines sounded normal throughout the accident sequence. Investigation revealed another Beech 18 had taken off on the same runway, but in the opposite direction of N916TM less than one minute prior to the accident.

As the cargo jet was taxiing for takeoff in a non movement area, it was struck by an airport employee shuttle bus. The airplane captain was seriously injured. Visual meteorological conditions prevailed, and the collision occurred during predawn hours. The bus driver said he stopped at the stop sign, turned on the 4-way flasher lights, and looked both ways. He saw one inbound aircraft to the right that had stopped. He did not see the airplane approaching from the left as he started across the cargo ramp. The airplane crew stated they did not see the bus until seconds before impact. Airplane skid marks, measuring 22 and 24 feet in length, were noted on the taxiway. No bus skid marks were noted on the roadway.

The float equipped airplane was observed taking off in light winds and calm water, and obtaining a steep climb and nose high attitude. Witnesses described hearing no reduction of engine noise from takeoff power to climb power. The airplane entered a steep left bank about 200 feet above the water, then rolled rapidly to the right and impacted at a steep angle into the water. The airplane had been modified with a Short Take Off and Landing (STOL) kit. Certification flight tests had determined that this modification eliminated aerodynamic warning of impending stalls, and therefore required an audible stall warning. Test results also required the addition of both a ventral fin, and horizontal stabilizer finlets, to meet directional stability certification. These tests determined that the least stable condition was in the takeoff flap configuration, during climb. The Supplemental Type Certificate (STC) for the modification required the ventral fin, and an audible stall warning system be installed. The manufacturer provided a marketing video, produced prior to the STC approval, which stated the stall warning system was not required in the U.S. The company indicated this tape was used for training, and was a basis for pilots routinely disabling the stall warning horn by pulling the circuit breaker. At the time of the accident, the airplane did not have the ventral fin installed, a takeoff flaps setting was selected, and the audible stall warning circuit breaker was in the pulled (disabled) position. The local FAA Flight Standards Office had inspected the accident airplane 14 times in the previous 29 months, and made no mention of the ventral fin not being installed.

The flight departed with 180 pounds of cargo after deplaning a passenger. Three company pilots overheard the accident pilot report that he was 13 minutes from his destination. The overdue aircraft was located by company airplanes about 700 feet MSL, on the east (downwind) side of an 890 feet msl pass. The airplane impacted on a 330 degree heading and perpendicular to the axis of the canyon/pass (oriented east-west), in a flat attitude, with no ground scars leading to the wreckage. No anomalies were found with the airplane, and all blades on the propeller exhibited torsional twisting and leading edge gouging. A westerly wind of seven to nine knots existed and numerous pilots reported the mountain passes were not obscured by clouds. Photographs from the pilot's camera depicted views of the accident canyon, with the pass and accident site above the altitude from which the photographs were taken. These photographs contained the date of the accident. Numerous depressant and stimulant, over-the-counter cold and asthma medications were found in the pilot's flight bag. Toxicological tests detected several over-the counter medications used for cold and asthma symptoms with illness effect of distraction or sensory disturbance. As a result of the condition for which the drugs were ingested may have also played a role in the accident.

The aircraft had an in-flight breakup when the left wing and tail section separated. Post accident inspection revealed a right engine main fuel supply line progressive rupture, only trace amounts of fuel in the fuel lines, and no rotational damage to the right engine. Pre accident, long term, fuel leak evidence surrounded the ruptured line. The right propeller was not feathered. The left wing D-tube rib at station 127 exhibited compressive buckling. Left wing fractures were upward, and horizontal stabilizer deformation was downward. During an actual loss of engine power in the airplane 17 months before this accident, the pilot had feathered the incorrect propeller. Both a mechanic, and an FAA safety counselor, who were familiar with the pilot, described him as able to be disoriented, and reliant on GPS for navigation. He had stated five months before the accident that he did not feel his instrument flying skills were proficient, and desired training. On the day of the accident, weather was visual meteorological conditions, with layered clouds above 2,200 feet mean sea level. The pilot stated to the FAA weather briefer that he wanted to make the flight under visual conditions. The flight route and altitude was unknown.