Alvarado, TX, USA
N8164R
Beech 95-B55
While maneuvering during a local instructional flight, the multiengine airplane entered a flat spin that resulted in an in-flight collision with the terrain. A witness, who holds a private pilot certificate, observed the airplane approximately 1,500 feet agl in a "flat spin," and the airplane impacted the ground "flat on its bottom" in a pasture, approximately 400 yards north of the witness. Another witness reported that the airplane was in a flat spin and could not recover. The private pilot with a multiengine rating occupied the left seat, and the multiengine flight instructor occupied the right seat. At the accident site, the landing gear actuator was found in the extended position, and the flap actuators were found in the 10 degree flap position. Examination of the right propeller revealed that the blade counterweight signature markings on the blade sockets indicated that the propeller was in the feathered position at impact. Examination of the right propeller unfeathering accumulator revealed the presence of three separate cracks at the transition between the circumferential stiffener and the thin-walled hemisphere of the diaphragm. The private pilot's toxicological tests indicated that 0.462 (ug/ml, ug/g) of Citalopram (also known by the trade name Celexa), 0.114 (ug/ml, ug/g) of N-desmethylcitapram, 0.024 (ug/ml, ug/g) of di-N-desmethylcitalopram, 0.194 (ug/ml, ug/g) of Diphenhydramine (commonly known by the trade name Benadryl) was detected in the blood and urine, and 17.406 (ug/ml, ug/g) acetaminophen was detected in the urine. Citalopram is a prescription antidepressant, N-desmethylcitapram and di-N-desmethylcitalopram are metabolites of citalopram, and diphenhydramine is an over-the counter antihistamine with sedative effects, often used to treat allergy symptoms. Diphenhydramine was detected in the private pilot's blood in levels consistent with the recent ingestion of several times a normal dose, and the pilot was likely impaired by the effects of diphenhydramine.
HISTORY OF FLIGHT On October 4, 2001, approximately 1315 central daylight time, a Beech 95-B55 twin engine airplane, N8164R, was substantially damaged after impacting terrain following a loss of control near Alvarado, Texas. The flight instructor and a private pilot, receiving instruction, were fatally injured. The airplane was owned by a private individual and operated by Alamo Aviation, Inc. of Arlington, Texas. Visual meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 instructional flight. The local flight originated from the Arlington Municipal Airport, Arlington, Texas, approximately 1215. According to personnel at the Alamo Aviation flight school, the private pilot was the owner of the flight school, and the flight instructor was the flight school's chief pilot/flight instructor. Approximately 1200, the general manager of Alamo dispatched the aircraft to the owner and flight instructor for a proficiency flight in the local area. A witness, who holds a private pilot certificate, reported that at 1315, he heard an aircraft flying overhead. He stated that there was a "noticeable change in engine sound," and he looked up, but did not see an airplane. A few seconds later, the witness heard the sound of an engine again, looked up to see an airplane approximately 1,500 feet agl in a "flat spin." He reported that at 200 feet agl, it seemed like one of the engines "rev[ed] up;" however, the "attitude of the airplane did not change." The airplane impacted the ground "flat on its bottom" in a pasture, approximately 400 yards north of the witness. Another witness stated that he heard an airplane having engine "trouble"; and subsequently observed the airplane approximately 1,000 to 1,500 feet agl. This witness reported that "the engines were constantly trying to start again, but would not take hold. The airplane was in a flat spin and could not recover." PERSONNEL INFORMATION The flight instructor held both a commercial pilot certificate with airplane multiengine land, airplane single-engine land, and instrument airplane ratings. The flight instructor held a certified flight instructor's certificate with airplane multiengine land, airplane single-engine land, and instrument airplane ratings. The flight instructor airplane multiengine land rating was issued on June 27, 1995, and the certificate was reissued on June 3, 2001, for an undetermined reason. The instructor was issued a second class medical certificate on September 27, 2001, with the limitation "Holder shall wear corrective glasses while exercising the privileges of his airman certificate." A review of the flight instructor's pilot logbook revealed, as of September 22, 2001, that the instructor had accumulated 9,170.6 hours of flight time, 8,781.4 hours as the pilot-in-command, and 7,604.7 total hours as a flight instructor, of which 670.4 hours was multiengine flight instruction. The flight instructor's most recent biennial flight review (BFR) was satisfactorily performed on June 23, 2001, in a single-engine airplane. The flight instructor's first flight in the accident airplane occurred on May 23, 2001, and he had logged 40.2 total hours in the airplane at the time of the accident. In the preceding 90 days, the flight instructor logged 154.8 total flight hours, of which 47.1 hours were multiengine instruction; and in the preceding 30 days, 19.6 total flight hours, of which 1.1 hours was multiengine instruction. In a statement provided by a pilot who completed an airplane checkout with the flight instructor, the pilot stated that the flight instructor "had me do the standard items for a checkout. Steep turns, stalls power on and off, engine out procedures. We shut down and feathered the right engine, then did a restart." In a statement provided by a pilot who had flight experience and completed multiengine training with the flight instructor, the pilot stated that during an aircraft checkout, a single-engine operation maneuver was performed. The pilot reported, "[flight instructor] gave me an engine failure by pulling back the left throttle to simulate the failure and then had me feather the left engine to feel the decrease in drag. He then had me unfeather the left engine by placing the left prop[eller] control into the high RPM position and having the unfeathering accumulator bring the prop[eller] out of the feathered position, which it did with no problems. This is the only time [flight instructor] would actually feather an engine and only within close distance to a nearby airport and only in straight and level flight. He never combined an engine feather with a maneuver such as a Vmc demo[nstration]." The checkout also included slow flight maneuvers using different configurations such as flaps and [landing] gear up or down. The private pilot, who occupied the left seat, was issued his private pilot certificate on December 31, 1997, and was issued his airplane multiengine land rating on October 25, 2000. The private pilot also held the instrument airplane and rotorcraft ratings. The private pilot was issued a third class medical certificate on December 2, 1999, with no limitations or restrictions. A review of the private pilot's logbook revealed that the private pilot had accumulated 316 hours total flight time, which included 61.7 hours multiengine, and 9.2 hours in the accident airplane. The private pilot logged his first flight in the accident airplane on August 18, 2001. In the preceding 90 days, the private pilot logged 22.4 hours total flight time, of which 9.2 hours was multiengine flight time in the Beech 55 airplane. In the preceding 30 days, the private pilot logged 5.0 hours total flight time of dual instruction in the accident airplane. The private pilot had logged a total of 13.1 hours of dual instruction with this flight instructor in a Piper PA-34-200 multiengine airplane. The accident flight was the flight instructor's first instructional flight with the private pilot in the accident airplane. AIRCRAFT INFORMATION The 1974 airplane was a Beech 95-B55, serial number TC-1746. The Beech 95-B55 is a twin-engine, low wing, all metal airplane of semimonocoque design, powered by two fuel injected reciprocating engines. The airplane was configured to carry a maximum of six occupants. The airplane was issued a FAA Standard Airworthiness Certificate on August 1, 1974, and was certified for normal category operations. At the time of the accident, the airframe had accumulated 7,896.7 total hours, 108.9 hours since the last annual inspection performed on November 17, 2000. No anomalies or discrepancies were recorded in the maintenance records during the annual inspection. The Hobbs meter indication at the last annual inspection was 2,197.3 hours. The left engine was a 260-horsepower Teledyne Continental IO-470-L, serial number (S/N) 454523 engine. At the most recent annual inspection, performed on November 17, 2000, the left engine total time was 6,859.3 hours, 690.4 hours since major overhaul (SMOH) on February 10, 1997. At the time of the accident, the left engine had accumulated 799.3 total hours SMOH. The right engine was a 260-horsepower Teledyne Continental IO-470-L, serial number 454233. At the most recent annual inspection, performed on November 17, 2000, the right engine total time was 7,156.4 hours (4,111.5 hours SMOH). At the time of the accident, the right engine had accumulated 4,220.4 hours SMOH. Airframe records dated July 9, 1982, stated in part: Installed [a] serviceable prop[eller] unfeathering accumulator on [the right/hand] R/H side and checked operational. The maintenance record for the right engine, dated April 9, 1990, stated in part: Serviced propeller accumulator with nitrogen." The maintenance records for the left engine, dated August 15, 1990, stated in part: re-installed propeller accumulator after overhaul by Accessories, Inc., P/N 95-380026A, S/N 22508. The left propeller was a three-bladed McCauley 3AF32C75-NR/82NC-6, hub serial number 721297, installed on the airplane on October 6, 1998. The right propeller was a three-bladed McCauley 3AF32C87-NR/82NC-6, hub serial number 702330, installed on the airplane on February 10, 1997. A review of the airframe, engine, and propeller maintenance records by the NTSB Investigator-In-Charge (IIC) did not reveal evidence of any anomalies or uncorrected maintenance defects prior to the flight. The airplane's most recent weight and balance was calculated on August 25, 1998, at a maximum approved gross weight of 5,100 lbs., a useful load of 1,693.5 lbs., and an empty center of gravity (CG) of 78.49 inches. At the time of the accident, the airplane weighed an estimated 4,632.5 lbs (467.5 lbs under the approved maximum gross weight). At a weight of 4,632.5 lbs., the airplane forward CG limit was 77 inches and the aft end of the CG limit was 86 inches. The CG was estimated to be 79.05 inches at the time of the accident. According to an employee at the Arlington Jet Fixed Base Operation (FBO), Arlington, Texas, he fueled the airplane with 31.2 gallons of 100LL aviation grade fuel at approximately 1215 on the morning of the accident, which "topped off" the fuel tanks. The total usable fuel for the airplane is 100 gallons. METEOROLOGICAL INFORMATION At 1256, the weather observation facility at the Fort Worth Mecham Airport (FTW), located 30 nautical miles northwest of the accident site, reported the wind from 170 degrees at 11 knots, visibility 10 statute miles, scattered clouds at 3,500 feet agl and a broken ceiling at 30,000 feet agl, temperature 28 degrees Celsius (82 degrees Fahrenheit), dew point 21 degrees Celsius (70 degrees Fahrenheit), and an altimeter setting of 29.98 inches of Mercury. WRECKAGE AND IMPACT INFORMATION The NTSB investigation team, who responded to the accident site, found the airplane in a pasture, located approximately 15 nautical miles south/southwest of the Arlington Municipal Airport. Examination of the accident site revealed that the airplane came to rest upright on a measured magnetic heading of 120 degrees. The Global Positioning System (GPS) coordinates recorded at the site were latitude North 32 degrees 21 minutes 44 seconds and longitude West 097 degrees 10 minutes 02 seconds. Ground scars were found under the airplane. The right wing, left wing, and fuselage exhibited upward crushing of the lower surfaces. The nose cone, engines and engine nacelles, fuselage, and vertical stabilizer were found displaced to the left. The cockpit and cabin floor was crushed upward toward the seat bases. The instrument panel remained intact; however, the left panel was bent aft, and several instruments were found separated from their respective mounting structure. The right hand side of the control horn for both control yokes was found separated and hanging by the electrical wiring from their respective control yoke. The left and right fuel selectors were found in the "ON" main tank position, respectively. The cockpit left and right throttle controls were found in the idle and mid-range positions, respectively; the left and right mixture controls were found in the midrange position respectively; and the left and right propeller controls were found forward and aft of midrange position, respectively. The left fuel pump switch was found in the "OFF" position. The right fuel pump switch was found separated, which precluded a determination for the position of the switch. The landing gear actuator was found in the extended position. According to the manufacturer's representative, the flap actuator was measured at 3 5/8 inches, which placed the flaps at the 10 degree approach flap position. The comm/nav 1 (communication/navigation) displayed Arlington Unicom frequency 123.07 Megahertz (MHz) and Maverick VOR frequency 113.10 MHZ frequency, respectively. The comm/nav 2 displayed Redbird Tower frequency 120.30 MHz and Maverick VOR 113.10 MHz frequency, respectively. The transponder displayed a squawk code of 1200. According to the manufacturer's representative, the elevator trim actuator measured 1 inch (3 degrees nose down position), the rudder trim measured 3.87 inches (neutral rudder position), and the left aileron trim measured 1.9 inches (9 degrees left aileron trim). Flight control continuity was confirmed from the cockpit area to the flight control surfaces. Both of the magneto switches were found in the left magneto position, respectively. The engines remained attached to their respective mounts and firewalls. The left engine was intact with both magnetos and the starter separated from their respective mounting structure, and the oil sump was found crushed upward. The throttle control linkage was attached and found in the forward to midrange position, the mixture control linkage was attached and found in the full rich position, and the propeller governor linkage was attached and found in the aft of mid-range position. The top spark plugs were removed, and according to the engine manufacturer's representative, displayed moderate wear (Champion spark plug wear guide) and light deposits in the electrode areas. The right engine was intact with both magnetos and the starter separated from their respective mounting structure, and the oil sump was found crushed upward. The throttle control linkage was attached and found in the full throttle position, the mixture control linkage was attached and found in the full rich position, and the propeller governor linkage was attached and found in the full forward position. The top spark plugs were removed, and according to the engine manufacturer's representative, displayed moderate wear (Champion spark plug wear guide) and light deposits in the electrode areas. Engine control continuity was confirmed for both engines from the cockpit controls to the engine controls by rotation of the crankshaft, thumb compression at each cylinder, and movement of the accessory gears. The left and right propellers remained attached to their respective propeller flange. All three blades on each propeller remained attached to their respective hubs. The left propeller spinner was found attached to the spinner bulkhead, which was displaced upward and exhibited deformation. All three propeller blades displayed chordwise scratching and were found loose in the hub. One left propeller blade was found buried into the ground, one blade was bent aft approximately 90 degrees, and one blade exhibited forward "S" bending with the outboard 1-foot twisted. On the right propeller, the outboard portion of one blade was bent aft approximately 30 degrees, one blade was curved aft, and one blade displayed a "S" bend. The propeller spinner remained attached to the spinner bulkhead, and the spinner was found crushed upward. The airplane wreckage was recovered to the Air Salvage of Dallas (ASOD) facility in Lancaster, Texas, for further examination under the supervision of the NTSB. Subsequently, the engines were forwarded to the Teledyne Continental Motors facility in Mobile, Alabama, and the propellers were forwarded to the McCauley Propellers facility in Vandalia, Ohio, for further examination under the supervision of the NTSB, respectively. MEDICAL AND PATHOLOGICAL INFORMATION Both autopsies were performed by the Johnson County Medical Examiner at the Walls Regional Hospital, Cleburne, Texas, on October 5, 2001. Specimens for toxicological tests were taken from both pilots by the medical examiner. The Federal Aviation Administration's (FAA) Civil Aeromedical Institute's (CAMI) Forensic and Accident Research center examined the specimens taken by the medical examiner. According to CAMI, both pilots toxicological testing showed no indication of alcohol at the time of the accident. The flight instructor's toxicology showed no indication of performance-impairing drugs at the time of the accident. According to CAMI, the private pilot's toxicological tests indicated that 0.462 (ug/ml, ug/g) of Citalopram (also known by the trade name Celexa), 0.114 (ug/ml, ug/g) of N-desmethylcitapram, 0.024 (ug/ml, ug/g) of di-N-desmethylcitalopram, 0.194 (ug/ml
The inadvertent flat spin of the airplane by the flightcrew resulting from the flight instructor's inadequate supervision. A contributing factor was the impairment (drugs) of the private pilot.
Source: NTSB Aviation Accident Database
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