Aviation Accident Summaries

Aviation Accident Summary MIA02FA170

McAlpin, FL, USA

Aircraft #1

N86GW

Beagle Aircraft B-206 Series 2

Analysis

The airplane impacted terrain in a nose low pitch attitude after the private pilot lost control during a turn from base to final approach. Witnesses located at the arrival airport reported the accident airplane flew a fairly "tight" right downwind pattern for runway 36 that was a "little low" (about 650 to 750 feet above ground level [agl]). The surface winds were from the east, and according to the witnesses, the result was that the pilot overshot his turn to final approach. The pilot corrected back toward the centerline in a fairly steep bank when the airplane was observed to enter a roll to the right, the nose dropped toward the ground. The witnesses then lost sight of the airplane as it descended behind trees in a nose low pitch attitude. Witnesses estimated the altitude of the airplane at the time of the roll was between 300 and 350 feet agl. The private pilot flew the airplane once within the preceding 6 months and twice within the past 12 months. No anomalies with the airframe or engines were noted that would have prevented their normal operation. According to the fixed-based operator, where the airplane was based, fueling personnel added 10 gallons to each wing prior to the accident flight; however, they were not sure what the airplane's total fuel quantity was. The unusable fuel quantity was 6.1 gallons. The fuel consumption rate varied between 24.4 and 33.0 gallons per hour depending on the power setting, and the accident flight lasted 35 minutes. No fuel was found in the fuel system components for the right engine with the exception of the fuel manifold. It was possible that the right engine's fuel supply line may have become unported during the steep bank to final; however, with an unknown fuel quantity, this could not be determined conclusively. Toxicology tests performed on the pilot were positive for tramadol (prescription painkiller) and chlorpheniramine (antihistamine, commonly used in over-the-counter cold/allergy preparations). Side effects for the drugs include dizziness, sleepiness, and performance degradation for complex cognitive and motor tasks. It is likely the use of the two drugs impaired the pilot's judgment and performance in pre-flight planning and in the flight itself.

Factual Information

HISTORY OF FLIGHT On September 21, 2002, about 1150 eastern daylight time, a Beagle Aircraft B-206 Series 2 airplane, N86GW, was destroyed when it collided with terrain while turning onto final approach for the Little River Airpark near McAlpin, Florida. The airplane was registered to and operated by SMM, Inc., as a 14 CFR Part 91 personal flight. The private pilot, who was the sole occupant, was fatally injured. Visual meteorological conditions prevailed and a flight plan was not filed for the flight that originated from Jacksonville, Florida's Herlong Airport about 1115. According to numerous witnesses who had assembled adjacent to runway 36 at the Little River private airpark, the pilot had not landed at the airpark before. The purpose of the flight was to determine if the twin-engine airplane fit in the hangar owned by a potential buyer on the airpark. One of the witnesses was in contact with the pilot via a handheld radio, and the aircraft was first sighted southeast of the airpark, flying westbound. The pilot was given vectors to help him locate the airpark, and once he sighted the field, he executed two circular orbits over the field. He then took a heading that would establish the airplane on a right downwind landing pattern for runway 36 (3,375 feet long by 50 feet wide, turf runway). Witnesses stated he flew a fairly "tight" downwind pattern that was a "little low" (about 650 to 750 feet above ground level [agl], as opposed to 1,000 to 1,500 feet agl). The surface winds were from the east, and according to the witnesses, the result was that the pilot overshot his turn to final approach. The pilot corrected back toward the centerline in a fairly steep bank when the airplane was observed to enter a roll to the right, the nose dropped toward the ground. The witnesses then lost sight of the airplane as it descended behind trees in a nose low pitch attitude. Witnesses estimated the altitude of the airplane at the time of the roll was between 300 and 350 feet agl. They also reported hearing a "pop" just as the aircraft entered the right roll. The aircraft impacted a grass field about 0.4 miles southwest of the airpark, in a rural housing area. PERSONNEL INFORMATION The pilot held a private pilot certificate with single-engine land, multi-engine land, and instrument airplane ratings. His most recent third-class medical certificate was issued on November 2, 2000, with the limitation, "Holder shall wear correcting lenses while exercising the privileges of his airman certificate." The pilot had satisfactorily completed a flight review as required by Federal Air Regulation, (FAR) 61.56 on January 31, 2002, in a Beech 35 single-engine airplane. The flight review lasted one hour and included slow-flight and steep turn maneuvers, power on and power off stalls, and emergency landings. The pilot's flight time, taken from the pilot's most recent logbook, totaled 1,863 flight hours, which consisted of 927 hours of single-engine airplanes and 914 hours of multi-engine airplanes. His total time as pilot-in-command equated to 1,717 hours. The last page of the pilot's logbook reflected entries from April 27, 2002 to September 6, 2002. Total flight time for the page was 25.3 hours, representing nine flights, all pilot-in-command, divided thusly: 24.7 hours in single-engine type aircraft and 0.6 hours flown on May 27, 2002, in N86GW. Since October 2001, the pilot logged two flights (totaling 4.1 hours) in the accident airplane. An acquaintance of the pilot reported he had logged approximately 300+ hours in the accident airplane AIRCRAFT INFORMATION The 1966-model airplane was powered by two 340-horsepower Teledyne Continental Motors GTSIO-520-C engines. The aircraft was being actively marketed by an aircraft broker, First Coast Aircraft Sales at Herlong Airport, for about a year prior to the accident. The aircraft underwent an annual inspection that was signed off on February 12, 2002, at an aircraft total time of 3,378 hours, and a Hobbs meter reading of 1,137.0 hours. That Hobbs time was also the time indicated on November 16, 2001, when the engine's oil was changed. Time displayed on the Hobbs at the accident site was 1,140.3 hours, or 3.3 hours in at last the last 10 months. According to the owner/operator of First Coast Aircraft Sales, the relative long period of inactivity of the aircraft at the end of 2001 and the beginning of 2002 was due to concerns by the owner, the annual inspector, and a Designated Engineering Representative (DER) concerning the remedy for a spot found on the left wing spar that had been exposed to paint stripper. The DER signed off on the repair on January 23, 2002, and the annual was completed and signed off on February 12, 2002. The engine logbooks revealed the left and right engine accumulated 131.3 and 1,141.3 hours since their last overhaul, respectively, at the time of the accident. The propellers had been changed at the same time as the left engine, and each had accumulated 131.3 hours since their last overhaul. The owner/operator of First Coast Aircraft Sales stated that the pilot/owner of N86GW had recently changed the Hoskins fuel management computer/indicator, and believed that the unit may not have been calibrated to the aircraft. He opined that its use by the pilot/owner may have been a factor in the accident. METEOROLOGICAL INFORMATION At 1252, the Lake City weather observation facility (located 18 miles east of the accident site) reported the wind from 070 degrees at 5 knots, visibility 10 statute miles, scattered clouds at 3,800 feet and 4,800 feet agl, temperature 92 degrees Fahrenheit, dew point 72 degrees Fahrenheit, and a barometric pressure of 29.91 inches of Hg. WRECKAGE AND IMPACT INFORMATION The wreckage site consisted of a vacant, grass and hard packed sand field fronting the 7500-block of 192nd Street in a rural housing area of McAlpin at coordinates 030.06.095 degrees north latitude by 082.54.075 degrees west longitude, and an elevation of about 94 feet mean sea level. Relative to the approach end of runway 36, the wreckage was located about 2,000 feet on a 195-degree magnetic bearing. Witness statements and wreckage evidence indicated the descent angle was steep enough that the wreckage remained essentially where first terrain impact occurred. The cabin area displayed aft crushing from the bottom side. The nose of the airplane was facing a 250-degree heading. The measurement of the aft crushing damage on the leading edges of the wings equated to 70 degrees nose down on the left wing and 50 degrees nose down on the right wing. A ground scar that indented the packed sand under the left wing was 4 feet longer than the left wing span. After terrain impact, the empennage remained stuck in the air. The empennage and aft fuselage, from a point 2.5 feet aft of the wing trailing edge, had sheared at a riveted lap joint and "jackknifed" upward and forward, resulting in the tip of the left horizontal stabilizer nearly contacting the aft left engine nacelle. McAlpin fire/rescue personnel arrived at the accident scene within minutes of the crash (they received an emergency call at 1230 and were on scene at 1237), and reported detecting no smell of fuel, no fuel escaping from the engines or fuel tanks, nor any evidence of fuel absorbed into the soil. Examination of the wing fuel tanks revealed both had been compromised and were void of fuel. About one gallon of fuel leaked from the left wing when the wreckage was moved. Type certification data sheets for the Beagle B-206 series 2 state that the unusable fuel quantity is 36 pounds or 6.1 gallons. Most of the windshield and window glass had shattered and was contained within about a 60-foot radius semi-circle oriented one o'clock to the wreckage heading. The landing gear were extended, and had collapsed rearward. The landing gear handle was in the "down" position, and the flaps were selected to the "takeoff" position. The right flap was found in the "takeoff" position, while the left flap was full down. The right flap hinges were found broken. Cockpit controls for trim were positioned close to "neutral" for rudder and aileron. Pitch trim was found at about a needle width beyond "takeoff" in the "nose up" position. Actual trim positions at the flight controls matched what had been selected in the cockpit. The left wingtip was detached and the left aileron was separated, but located in its normal position. The right aileron's outboard hinge was broken. Flight control continuity along all three axes was confirmed from the flight control surfaces to a location under the floorboards of the cockpit. Damage to the floorboard area precluded further examination. Examination of the cockpit engine controls revealed that the left throttle was full forward, while the right throttle was about 1-inch aft of full forward. The mixture controls were both full forward, and the left propeller control was about midrange, while the right propeller was at full rpm. Both magnetos were in the "both" position, the fuel boost pumps were on, and both alternators were on. The left engine fuel selector was positioned to "left tank" and the right engine selector was positioned to the "right tank". The cowl flap switches were positioned to "open," which matched the position noted on the engine cowlings. The fuel quantity gages indicated 280 pounds for the left tank and 60 pounds on the right. Fuel pressure gages displayed "5" psi on the left and "0" psi on the right. Both propellers were buried in the sand, and when the wreckage was removed, the three craters made by the engines and nose were about 2.5 feet deep. The right propeller had separated at the crankshaft flange, and both engines had about a 20-degree droop within their respective mounts, once the wreckage was dragged from the wreckage crater. Examination of both 3-bladed, "Q-tip" type propellers revealed slight bending damage and sand burnishing. The left propeller blades displayed more burnishing and blade bending damage than the right. One left propeller blade revealed a 10-degree rearward bend at mid-span and burnishing for the outer 1/2 span; the second left blade revealed a slight "S" bend of the full span and leading edge burnishing for the full span; the third left blade revealed a slight "S" bend of the full span and leading edge burnishing of the full span and full chordwise burnishing of the outer 1/4 span. One right blade displayed relatively little damage; the second right blade had a 5-degree rearward bend from 1/3 span, outward, with slight burnishing of the outer 2/3 span; and the third right blade displayed a 20-degree bend from mid-span outward, with the outer 1/3 span slightly burnished. Fuel found in the left engine, and its components, equated to about 3 tablespoons of uncontaminated 100 octane low-lead (100LL) fuel in the fuel distribution valve, approximately one cup of fuel in the engine driven fuel pump, and one cup of fuel in the pump hoses. No fuel was found in the right engine fuel pump and its hoses, and just a trace of uncontaminated fuel was found in the fuel distribution valve. Both oil filters were cut open, and found free of contamination. Both sets of magnetos were rotated and a spark as produced on the top ignition leads. Both engine crankshafts were manually rotated to check for valve train and accessory drive continuity, and cylinder compression. Except for impact damage to the right engine No. 6 exhaust rocker arm area, all cylinders and drive trains indicated normal operation. The top spark plugs for both engines were removed and revealed normal electrode deposit coloration per the Champion Spark Plugs Check-A-Plug Chart AV-27. The exception was a slightly darker color to plug No. 1 of the right engine. Both engines' induction and exhaust systems were free from obstructions; however, both exhaust systems sustained crushing damage. The right engine fuel control's filter contained "fuzz" on the bottom 1/4 of the filter screen. The wing fuel filler caps exhibited a rusty, deteriorated appearance when removed by investigators. The pilot was using a lap belt that was cut by first responders to facilitate his removal from the wreckage. Examination of the seatbelt revealed it operated satisfactorily. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot at the Jacksonville, Florida Medical Examiner's Office. According to the chief medical examiner's report, the pilot died as a result of multiple injuries sustained in the accident. Postmortem toxicological testing on specimens from the pilot was performed by the FAA Toxicology and Accident Research Laboratory in Oklahoma City, Oklahoma. Tests results revealed that chlorpheniramine was detected in the pilot's blood and urine. Additionally, 0.125 ug/mL of tramadol was detected in the pilot's blood and an unquantified amount was detected in his urine. The pilot's son was not aware of his father's use of the medications. Both the son and the pilot's Aviation Medical Examiner stated that the pilot was probably taking the Tramadol for shoulder pain as a result of handball playing soreness. Reading type vision correction glasses were found with the pilot at the accident site. ADDITIONAL INFORMATION Before the flight departed Herlong Airport, the pilot ordered 10 gallons of 100LL aviation fuel pumped into each wing tank. The fueler stated that the fueling did not represent a top-off, and that he did not know to what level the 10 gallons on each side brought the airplane's total fuel. The fuel had been examined and certified to be uncontaminated by the fixed base operator, (FBO). The home-base FBO for N86GW was Herlong Aviation, and the owner/manager stated, based on past experience, it was normal for N86GW to have no or low fuel onboard before they got the request for refueling. His records show that prior to the refueling of September 21, 2002, N86GW was fueled with 40 gallons on June 15, 2002, and had flown twice since then. The pilot informed a Herlong Aviation employee that he had planned the flight to Little River Airpark along a course of 260 degrees (true) and a cruise altitude between 2,500 to 3,000 feet msl, and estimated that it would take about 18 minutes from Herlong Airport. The distance between Herlong and McAlpin is 58 nautical miles. The cruise performance section of the operating handbook for the Beagle B-206 Series 2 airplane indicated that the fuel consumption for a 55%, 65%, and 75% power setting would be 147 pounds/hour, 172 pounds/hour, and 199 pounds/hour, respectively. Based on the length of the flight and depending on the power setting utilized by the pilot, the engines could have consumed between 14.64 and 19.80 gallons of fuel. The unusable fuel quantity was 6.1 gallons. The fuel tanks incorporates three flap valves, which prevent "fuel surge starvation of the booster pump and engine pipe lines during banked flight." The wreckage was released to the owner's representative on September 23, 2002. The pilot's flight records were released to the pilot's son on January 21, 2003.

Probable Cause and Findings

the pilot's failure to maintain an adequate airspeed to sustain controlled flight, which resulted in an inadvertent stall during a turn from base to final. A contributing factor was the pilot's use of judgment and performance impairing drugs.

 

Source: NTSB Aviation Accident Database

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