Oklahoma City, OK, USA
N9112S
BEECH V35
The airplane had a previous history of in-flight engine stoppages, and the engine lost power twice within the week before the accident. The pilot did not have his mechanic investigate the cause of those events, as he believed when the engine lost power the airplane was in a fuel cross feed position, and all he had to do was to switch to a main fuel tank. On the day of the accident the airplane was two miles from the airport after departure when the pilot reported a loss of engine power to air traffic controllers. The pilot executed an off-airport emergency landing to a congested area, adjacent to a major six-lane thoroughfare. The airplane was substantially damaged when it impacted a tree and the concrete base of a light pole, during the emergency landing. The engine was recovered from the wreckage and installed in an engine test cell. It started on the first attempt and ran at full throttle with no anomalies noted. A postexamination of the other airplane systems showed no anomalies. The pilot had been treated for anxiety, depression, high blood pressure, and obstructive sleep apnea, among other significant conditions. He had been on multiple medications at the time of the accident including at least an antidepressant, a blood thinner and a potentially impairing prescription medication often used for the treatment of chronic pain. The pilot denied any medical conditions or the use of medications in his most recent application for an airman medical certificate. It was not possible to conclusively determine whether distraction or impairment due to his medical conditions or to medication use may have played a role in his decision-making following the loss of engine power. The pilot’s fatal injuries were likely a result of the impact between his chest and the control yoke. It could not be conclusively determined the extent to which the forward cabin structure and the control yoke in particular were moving aft relative to the rest of the cabin structure following the primary impact with the ground, but it is possible that the likelihood or severity of the pilot’s impact with the control yoke would have been reduced through the availability and use of a shoulder harness.
HISTORY OF FLIGHT On July 25, 2009, 0852 central daylight time, a Beech V35/B, N9112S, lost power during climb and impacted terrain one mile north of the Wiley Post Airport (PWA), Oklahoma City, Oklahoma. The personal flight was being conducted on a visual flight rules (VFR) flight plan under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The airplane was substantially damaged. The pilot was fatally injured, and the four passengers were seriously injured. Visual meteorological conditions prevailed at the time of the accident. The flight had originated from PWA at 0847 and was enroute to the Enid Woodring Regional Airport (WDG), Enid, Oklahoma. The airplane was on a northerly course two miles northeast of PWA when the pilot reported ”we’ve got an engine out”. The pilot executed an off-airport emergency landing. The airplane impacted a tree and the concrete base of a light pole. It remained upright, coming to rest in a grassy area next to a road approximately 100 feet from the initial impact point. According to first responders there was a significant fuel spill, but no post impact fire. An aircraft broker that was assisting the pilot with the sale of N9112S said he had never before flown with him until July 21, 2009. On that date they flew in N9112S from the PWA airport to the Larned-Pawnee County Airport (LQR), Larned, Kansas. The pilot did all the flying for all legs of the entire trip. At one point while in-flight, the autopilot somehow became disengaged. The aircraft broker could see that the pilot was not monitoring the airplane and did not seem to realize that the autopilot had failed until he mentioned that they were in a climbing left turn. Describing the first landing at the LQR airport, the aircraft broker said the pilot was “really hot” on the approach. They had a landing speed of 110 knots over the numbers and a very long landing. Just after touchdown the “engine just quit”, but the pilot was able to restart it and they resumed taxiing in to the ramp. They then met the prospective customer at LQR, who said he wanted to fly to the Garden City Regional Airport (GCK), Garden City, Kansas, to have his mechanic look at the airplane. During the flight from LQR to GCK and the return flight to LQR, the pilot did all of the flying with the customer in the right seat and the aircraft broker in a rear seat. During arrival at GCK, the customer wanted to see an autopilot coupled approach, but the pilot did not seem to be familiar enough to configure the autopilot and had to resort to hand flying the airplane on final approach. The aircraft broker said that every landing he had seen with the pilot was “very fast”. He said the pilot did not seem to be in control of the airplane and the airplane seemed almost to be “flying him”. The pilot rated customer, in the front seat, also mentioned the pilot’s difficulties with the autopilot and his fast landing speeds. Both the aircraft broker and the customer commented about the pilot’s decision to fly the airplane through clouds during the flight to GCK, when he did not have an instrument flight rules (IFR) clearance to operate in clouds. The aircraft broker and the customer both expressed their concern to the pilot, and he remained clear of clouds during the return flight to LQR. The aircraft broker said he had a face to face conversation with the pilot on July 23, 2010. The pilot told him about a flight on the previous day when he was trying to cross-feed on the tip tank and the engine quit in-flight. He was able to immediately restart the airplane by switching to a full main tank. The aircraft broker then advised the pilot that he shouldn’t fly the airplane again until he got his mechanic to look at the problem. A mechanic, who had been performing maintenance on N9112S for several years, said the pilot had earlier spoken with him about two previous instances when the engine had quit in-flight while “cross-feeding” from the auxiliary fuel tanks, and the mechanic had then made a repair to a loose switch in the panel. The mechanic was not asked to perform any repairs after July 20, 2009/ The pilot’s wife, a frequent passenger, said she could remember at least two times on previous flights when the engine had quit while they were flying, but each time he was able to get it restarted. She said he was a very good pilot and she was comfortable flying with him. PERSONNEL INFORMATION The pilot, age 59, held a private pilot certificate with a airplane single-engine land rating, and a instrument airplane rating. The pilot was issued a restricted third-class medical certificate on October 9, 2008. The pilot completed a biennial flight review (BFR) on July 20, 2009. Examination of the pilot’s log book showed that he had logged a total of 1,459 hours of pilot experience. He had an estimated total of 315 hours of pilot experience in the same make and model airplane, and 12 hours of pilot experience in the accident airplane within the past 90 days. AIRCRAFT INFORMATION N9112S, serial number (S/N) D-9856, a model V35/B, was manufactured by the Beech Aircraft Corporation in 1976. It was a low-wing, single engine land airplane. The airplane was originally delivered with a Continental IO-520-BA engine, S/N 562199 rated at 285 horsepower. At the time of the accident it was powered by a Continental IO-520-BB engine, S/N 830058-R, rated at 285 horsepower, driving a McCauley 3-blade, constant speed, aluminum alloy propeller. The airplane was issued a standard airworthiness certificate on February 12, 1976, in the normal category. The airplane was registered to the owner on August 11, 2005. The airplane was configured with two seats in the cockpit area, two passenger seats in a second row, and two seats in a third row. There was one cabin door next to the right front seat passenger. Each of the six seats was equipped with a seat belt. The airplane was not equipped with shoulder harnesses (Because of the airplane's year of manufacture shoulder harness installation was not required). The airplane was equipped with a Garmin GNS 430W navigation and communications unit, and a JP Instruments EDM-700 electronic engine analyzer. At the time of the accident, the pilot was also using a Garmin GPS Map 496 handheld global positioning system (GPS). The aircraft maintenance records available during the investigation showed that the most recent annual inspection was completed on May 23, 2008, at a tachometer time and aircraft total time of 2,046.9 hours, and an engine total time of 388.9 hours. Records show that a new annual inspection had been substantially completed on July 20, 2009, but the inspection authority mechanic was waiting for a replacement for an illegible fuel placard. He was also waiting for a logbook entry from a local sheet metal shop for a repair that had been completed. At the time of the accident, the airplane had accumulated a total time of 2,094.9 hours, and an engine total time of 436.9 hours. METEOROLOGICAL INFORMATION At 0853, the automated weather observing system at the PWA airport reported winds from 220 degrees at 10 knots, visibility of 10 miles, skies clear, temperature 82 degrees Fahrenheit, dew point 63 degrees Fahrenheit, with an altimeter setting of 29.93 inches of Mercury. AIRPORT INFORMATION The Airport/ Facility Directory, Southwest U. S., indicated that runway 17L/35R at the PWA airport was 7,199 feet long and 150 feet wide. The runway surface was composed of concrete. WRECKAGE AND IMPACT INFORMATION The accident site was located on a grassy lawn area in front of a banking facility and was adjacent to a major six-lane thoroughfare inside the city limits. A handheld GPS showed an accident site location of 35 degrees, 33 minutes, 18 seconds north latitude, and 097 degrees, 37 minutes, 52 seconds west longitude, at an estimated elevation of 1,224 feet mean MSL. Investigators from the Federal Aviation Administration (FAA), Transportation Safety Institute (TSI), and Hawker Beechcraft Corporation (HBC) examined the wreckage at the accident scene on July 25, 2009. Investigators from the Safety Board, FAA, and TSI again examined the accident scene, and examined the wreckage of the airplane on July 28, 2009. A damaged 30 foot tall tree, struck by the airplane, was observed with limbs and other debris scattered on a 285 degree bearing for approximately 100 feet. A grass kill of more than 2,000 square feet was observed extending from the tree struck by the airplane and continued in the direction of the spot where the main wreckage was located. The airplane was observed upright and oriented on a heading of 140 degrees. All portions of the airplane were found at the accident location. The leading edges of both wings of the airplane had impact damage and vegetation smears that corresponded to the damaged tree. The front portion of the right tip tank had separated from the airplane and was found ten feet southwest of the concrete base of a light pole. Smears of paint and impact damage on the leading edge of the tip tank corresponded to impact marks on the concrete base of the light pole. First responders had used the “jaws of life” to cut the roof pillars and peel back the roof. The cabin area was exposed. The engine was separated from the engine mounts, but remained attached to the airframe by cable and control lines. The flaps were observed in the up position and the landing gear was observed in the up position. The fuel selector valve was observed in the left main tank position, The battery switch and alternator switch were found in the on position. The magneto switch was found in the off position. The aux fuel pump switch was found in the off position and operated freely. The tip cross feed switch, located next to the fuel selector valve, was separated from its mounting location. Its switch position could not be determined. After the wreckage was lifted and moved to a nearby storage hangar, the investigators observed damage to the sump drain valves on both wings. The pointer of the Osborne five position fuel selector valve was felt and observed to be at the detent of the left main tank position. The fuel selector valve moved freely in all positions and was removed from the airplane and examined. The only fuel line that contained visible fuel was the line from the selector valve to the boost pump. The electric fuel boost pump was removed from the airplane and electric power was applied. The pump operated; however, only a small amount of fuel was found in the lines to the fuel pump. The fuel selector valve, the EDM-700 electronic engine analyzer, and the GPS Map 496 handheld GPS were removed for examination. PATHOLOGICAL INFORMATION The pilot’s most recent application for 3rd class Airman Medical Certificate, dated October 9, 2008, indicated “No” in response to “Do You Currently Use Any Medication” and to all items under “Medical History,” including specifically “Heart or vascular trouble,” “High or low blood pressure,” “Mental disorders of any sort; depression, anxiety, etc.,” and “Other illness, disability, or surgery.” The application also indicated “No” in response to “Visits to Health Professional Within Last 3 Years.” Medical records obtained from a hospital at which the pilot had shoulder replacement surgery performed on June 10, 2008 documented an extensive medical history, including longstanding shoulder pain, high blood pressure, back problems, prostate problems, an irregular heartbeat, elevated, cholesterol, and depression and anxiety with panic attacks. Those records noted current medications to include clonidine, verapamil, hydrochlorothiazide, terazosin, simvastatin, aspirin, and unspecified medications for depression and for anxiety. The pilot’s spouse indicated that the pilot had recently undergone “artery surgery,” used a CPAP (continuous positive airway pressure) machine every night while sleeping, and had a “very bad sinus allergy.” Post accident medical records documented the use of atropine and lidocaine in resuscitation efforts. The autopsy report on the pilot noted the following “Pathological Diagnoses”: I. Multiple blunt force injuries A. Cardiac contusion B. Laceration of left lung C. Bilateral hemothorax (100 cc right, 100 cc left) D. Fracture of the sternum E. Multiple rib fractures, bilateral F. Apparent fracture of lumbar spine (LI-L2 region) G. Closed fracture, right lower leg H. Multiple contusions, abrasions, and small lacerations II. Heart A. Severe atherosclerosis of the proximal portion of the left anterior descending coronary artery (with up to approximately 75% luminal stenosis) B. Concentric left ventricular hypertrophy C. Cardiomegaly (560 g) III. Mild obesity (BMI = 30.6) The autopsy report noted the “Cause of Death” as “Multiple injuries, blunt force.” The toxicology report stated: NO CARBON MONOXIDE detected in Blood; NO CYANIDE detected in Blood; NO ETHANOL detected in Vitreous; ATROPINE detected in Blood; CLOPIDOGREL detected in Urine; CLOPIDOGREL detected in Blood; 0.076 (ug/mL, ug/g) DESMETHYLSERTRALINE detected in Blood; DESMETHYLSERTRALINE detected in Urine; GABAPENTIN detected in Urine; GABAPENTIN detected in Blood; LIDOCAINE detected in Urine; LIDOCAINE detected in Blood; 0.038 (ug/mL, ug/g) SERTRALINE detected in Blood. The clinical report stated: 51 (mg/dl) GLUCOSE detected in Vitreous; 145 (mg/dl) GLUCOSE detected in Urine; 5.4 (percent) HEMOGLOBIN A1C detected in Blood. TESTS AND RESEARCH Investigators from the Safety Board, HBC, and Teledyne Continental Motors (TCM) examined the engine at the Teledyne Continental Motors facilities in Mobile, Alabama, on October 20, 2009. The engine exhibited impact damage concentrated at the oil sump and engine mounts. The remaining external surfaces of the engine were intact. A dye penetrant inspection was performed on the crankshaft propeller mount flange; there were no crack signatures evident. The cylinders were inspected with a bore scope and there were combustion deposits present in the combustion chamber and on the piston head. There was corrosion present on the cylinder bore. The cylinder head combustion chamber, intake and exhaust valve faces, piston head and cylinder bore exhibited normal operating signatures. The cylinder bore finish was steel. After documentation of the damage, substitute parts to replace impact damaged parts were installed and the engine was prepared for installation in an engine test cell. The engine was not disassembled prior to the engine run. During installation in the test cell, the engine was fitted with a test club propeller. The engine experienced a start on the first attempt without hesitation or stumbling in observed RPM. The engine RPM was advanced in steps to prepare for full power operation. The throttle was advanced to 1,200 RPM and held for five (5) minutes to stabilize. The throttle was advanced to 1,600 RPM and held for five (5) minutes to stabilize. The throttle was advanced to 2,450 RPM and held for five (5) minutes to stabilize. The engine throttle was rapidly advanced from idle to full throttle six times. Throughout the test phase, the engine accelerated normally without any hesitation, stumbling or interruption in power and demonstrated the ability to produce rated horsepower. No pre-impact anomalies of the engine were observed that would have precluded normal operations. On September 28, 2009, a Safety Board investigator, examined the fuel selector valve at the facilities of Osborne Tank and Supply, Victorville, California. The fuel selector valve, S/N 55034, part number (P/N) 288, manufactured by Osborne Tank and Supply had been removed from the accident airplane. Osborne’s procedures for leak check, pressure tests, and liquid flow tests were performed on the fuel selector valve. All function tests were passed. There were no noted flow restrictions or visible leaks. The airplane's JP Instruments EDM-700 electronic engine analyzer, and a handheld Garmin GPS Map 496 global positioning system (GPS) were examined at the National Transportation Safety Board's Vehicle Recorder Division, in Washington, D.C. Data
The pilot’s decision to operate an airplane with known deficiencies, and the loss of engine power during climb for undetermined reasons.
Source: NTSB Aviation Accident Database
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