Holbrook, AZ, USA
N912T
BEECH B95
After landing, the pilot told witnesses that he vomited en route to the airport. After fueling, he went into the airport lounge, and laid down on a sofa in a fetal position. The witnesses stated that he looked ill, referring to him as clammy or pale. After the passengers returned from lunch, they boarded the airplane. A professional pilot saw the airplane depart in a direction such that the wind varied from a quartering tailwind to a direct crosswind at 5 to 10 knots. The airplane climbed about 300 feet, made a 45-degree right turn, then entered a left turn, and appeared to be returning to runway 21. As the airplane rolled through the extended centerline of the runway, the bank angle increased until the left wingtip was pointed at the ground. The airplane continued to roll until the nose was pointed toward the ground before impact. Examination of the wreckage revealed no mechanical anomalies with the airframe or engine. It was very likely that the acute gastrointestinal distress the pilot was suffering at the time impaired his ability to successfully fly the airplane. Due to his condition, the pilot likely decided to return to the departure airport, but failed to maintain control of the airplane. The pilot’s toxicology report revealed distant use of propoxyphene, a pain medication. No personal medical records were found, so it was not possible to determine of the effect of the underlying painful condition. However, the distant use of the medication was unlikely to have impaired the pilot or caused his gastric distress at the time. Phentermine was also identified in the toxicology report; this medication carries an FDA warning “may impair the ability of the patient to engage in potentially hazardous activities such as operating machinery or driving a motor vehicle.” The use of phentermine may have further impaired the pilot’s ability to safely fly the airplane, and may have played a role in his willingness to attempt a flight while suffering from nausea and vomiting.
HISTORY OF FLIGHT On June 24, 2009, about 1700 mountain standard time, a Beech B95, N912T, collided with terrain at Holbrook, Arizona. The pilot/owner was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The commercial pilot and three passengers sustained fatal injuries; the airplane sustained substantial damage from impact forces and a post crash fire. The cross-country personal flight was departing with a planned destination of Largo Vista, Texas. Visual meteorological conditions prevailed, and no flight plan had been filed. The pilot contacted the Prescott, Arizona, Automated Flight Service Station (AFSS) at 0934 for a standard weather brief. He indicated that he would depart Santa Rosa, California, in 20 minutes, and the en route altitude would be 11,500 feet. Witnesses reported that the pilot stopped for fuel at Holbrook on June 23, and indicated that he was going to California. The pilot landed at Holbrook about 1600 the day of the accident, and stated that he was returning to his home in Texas. While the passengers drove to town for lunch, the pilot stayed at the airport. He fueled the airplane at the self-service pump, and told the witnesses that they shouldn’t touch the left wing as he had become nauseated en route, and vomited out the pilot side vent window. After fueling, he went into the airport lounge, and lay down on a sofa in a fetal position. The witnesses stated that he looked clammy and pale. After the passengers returned from lunch, they boarded the airplane with the pilot. The witnesses stated that the airplane started without difficulty, and they noted no fluid leaks or smoke as the airplane taxied for takeoff. A professional pilot observed the taxi and takeoff on runway 03. He stated that the wind was from 240 to 270 degrees at 5 to 10 knots. The airplane seemed to have an extended ground roll, and lifted off approximately 3,500 feet down the 7,000-foot runway. The airplane climbed to about 300 feet above ground level, and made a 45-degree right turn. Then, it entered a left turn, appearing to return towards runway 21. As the airplane rolled through the extended centerline of the runway, the bank angle increased until the left wingtip was pointed at the ground. The airplane continued to roll until the nose was pointed toward the ground prior to impact. The witness observed smoke, and instructed the other witnesses to call for emergency services. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed that the 45-year-old pilot held a commercial pilot certificate with ratings for airplane single-engine land, multiengine land, and instrument airplane. The pilot held a certified flight instructor (CFI) certificate with ratings for airplane single-engine land, multiengine land, and instrument airplane. The pilot held a first-class medical certificate issued on December 8, 2008. It had no limitations or waivers. 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 medical application that he had a total time of 4,100 hours with 200 hours logged in the previous 6 months. On an application for insurance dated October 20, 2008, the pilot reported a total time of 4,200 hours; 700 hours in multiengine airplanes with 300 hours in make/model. He reported 300 hours in the previous 12 months. AIRCRAFT INFORMATION The airplane was a Beech B95, serial number TD-364. No maintenance logbooks were recovered for the airplane. The left engine was a Textron Lycoming O-360-A1A, serial number RL-36344-36A. The right engine was a Textron Lycoming O-360-A1A, serial number L-12594-36A. Fueling records at Holbrook established that the airplane was last fueled prior to takeoff with the addition of 65 gallons of 100-octane low lead aviation fuel. METEOROLOGICAL INFORMATION An aviation routine weather report (METAR) for Winslow (KINW), Arizona, was issued at 1656 MST. Winslow was 33 nautical miles (nm) at 280 degrees from Holbrook. It stated: wind from 260 degrees at 13 knots; visibility 10 miles; sky clear; temperature 33 degrees Celsius; dew point 4 degrees Celsius; altimeter 30.03 inches of mercury. AIRPORT INFORMATION The Airport/ Facility Directory, Southwest U. S., indicated that Holbrook runway 03 was 6,698 feet long and 75 feet wide. The runway surface was asphalt, and it had a displaced threshold of 800 feet. WRECKAGE AND IMPACT INFORMATION Investigators examined the wreckage at the accident scene. The site was in desert terrain at an elevation of 5,263 feet about 1 mile northeast of the airport. The first identified point of contact (FIPC) was a ground scar in soft dirt. The debris path was oriented along a magnetic heading of 240 degrees, and the orientation of the fuselage was 060 degrees. The wings exhibited symmetrical leading edge crush damage that went aft to the spar. Fire consumed the skin in the fuselage and inboard portions of both wings. The right engine separated from the airframe; the right propeller remained attached to the right engine. The left engine was inverted on top of the left wing remains; the left propeller separated from the left engine, and its fracture surface was jagged with a circumferential shear lip. The tail section remained together as a unit, and paint scorching stopped just in front of the leading edge of the horizontal and vertical stabilizers. Investigators established control continuity for the elevators and rudder. They established continuity from the left aileron to the center of the fuselage; the control cable separated mid cabin. The right aileron bellcrank separated from the fuselage. The rod end for the bellcrank fractured and separated inside the wing; the rod end was bent, and the fracture surface was angular. One control yoke had the chain in place around its sprocket; the chain and control column separated at its base in a jagged and angular pattern. The aileron and rudder trim tabs appeared to be in a neutral position. MEDICAL AND PATHOLOGICAL INFORMATION The Forensic Science Center in Tucson, Arizona, completed an autopsy on the pilot for the Navajo County Sheriff’s Department. They determined that the cause of death was blunt impact to the head, torso, and extremities with severe internal injuries. The FAA Forensic Toxicology Research Team, Oklahoma City, performed toxicological testing of specimens of the pilot. Analysis of the specimens contained no findings for carbon monoxide. They did not perform tests for cyanide. The report contained the following findings for volatiles: 10 (mg/dL, mg/hg) ethanol detected in muscle; no ethanol detected in the liver. The report stated that the ethanol found in this case was from sources other than ingestion. The report contained the following findings for tested drugs: 0.143 (ug/ml, ug/g) norpropoxyphene detected in liver; 0.044 (ug/ml, ug/g) norpropoxyphene detected in blood; phentermine detected in liver; and 0.585 (ug/ml, ug/g) phentermine detected in blood. The NTSB medical officer reviewed the pilot’s FAA certified medical records, toxicology report, and autopsy report. The medical officer’s factual report is in the public docket, and pertinent excerpts follow. Norpropoxyphene is an inactive metabolite of propoxyphene, a narcotic pain medication prescribed as a Schedule IV controlled substance, and previously marketed under the trade name Darvon. According to the FDA, phentermine is a sympathomimetic amine used as a prescription appetite suppressant (intended only for short term use) in obese patients with BMIs over 30kg/m2. According to the pilot’s last medical, he was 70 inches tall and weighed 191 pounds (BMI = 27.4 kg/m2). Because of its chemical relationship to amphetamine and significant potential for abuse, phentermine is a Schedule IV controlled substance. It is marketed under the trade name AdipexP. Therapeutic levels are considered between 0.1800 and 0.5100ug/ml. TESTS AND RESEARCH Investigators examined the wreckage at Air Transport, Phoenix, Arizona, on June 26-27, 2009. They detected no evidence of preimpact mechanical malfunction of the recovered airframe and engine. The examination report is part of the public docket for this accident. ADDITIONAL INFORMATION Investigators discovered several packages of a substance identified by law enforcement as marijuana in the baggage compartment. A friend and one victim had a telephone conversation in which the victim stated that the airplane had struggled getting off the ground at Holbrook on the outbound leg. The victim was concerned about going through there again on the return trip.
The pilot’s decision to depart when ill and his failure to maintain control of the airplane during a return to the airport, likely because of his physical illness and drug impairment.
Source: NTSB Aviation Accident Database
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