Birmingham, AL, USA
N48TS
BEECH 58P
During the approximately 5 hour and 25 minute night instrument cross-country flight in a multi-engine airplane, the pilot elected not to stop at his planned fuel stop. Upon reaching the destination airport, the weather conditions included an overcast ceiling at 300 feet and 2 miles visibility in drizzle, which were worse than the forecast conditions of overcast ceiling at 1,000 feet and 6 miles visibility. The pilot diverted to his planned alternate airport and attempted an instrument landing system approach. Given the lack of a fuel stop, the pilot may have felt personal pressure to land the airplane as soon as possible. The airplane initially intercepted the localizer for the approach, but did not intercept the glideslope. The airplane then proceeded left of course, above the glideslope, followed by a continued left deviation and descent below the glideslope. The tower controller asked the pilot if he was still on the localizer course and the pilot replied that he was not. The tower controller then provided heading and altitude instructions in an attempt to guide the pilot onto a missed approach. The pilot acknowledged the heading instruction, but failed to turn to the assigned heading or climb to the assigned altitude. The airplane subsequently impacted a residential area about 1/2 mile from the runway. The pilot's logbook was not recovered and a determination of his flight experience in actual instrument conditions could not be made. According to a flight instructor, the pilot had owned the accident airplane for about 6 months and had 80 to 90 hours in the make and model. The pilot completed an instrument proficiency check with the instructor about 1 month prior to the accident. The instruction included many instrument approaches and missed approach procedures. Additionally, the flight instructor concentrated on attitude flying, which was not the pilot's strongest skill. Examination of the wreckage did not reveal any preimpact mechanical malfunctions. If neither horizon nor surface references exist, the attitude of an airplane must be determined by artificial means from the flight instruments. However, during periods of low visibility, the supporting senses sometimes conflict with what is seen; when this happens, a pilot is particularly vulnerable to disorientation. Postmortem toxicology testing noted findings consistent with marijuana use; however, no blood was available for toxicological testing and it was not possible to reliably estimate when the marijuana may have most recently been used or whether the pilot may have been impaired by such use.
HISTORY OF FLIGHT On January 5, 2011, at 1846 central standard time, a Beech 58P, N48TS, operated by a private individual, was substantially damaged when it crashed during approach to Birmingham International Airport (BHM), Birmingham, Alabama. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Night instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed. The certificated private pilot was killed. The flight originated from Morristown Municipal Airport (MMU), Morristown, New Jersey, about 1320. According to air traffic control data from the Federal Aviation Administration (FAA), the intended destination for the flight was Shelby County Airport (EET), Alabaster, Alabama, with a stop at Mountain Empire Airport (MKJ), Marion, Virginia, possibly for fuel. The departure from MMU and enroute flight were uneventful. At 1602, the pilot advised air traffic control (ATC) that he was not going to land at MKJ, and continued to EET. Upon nearing EET, and obtaining the local weather at that airport, the pilot elected to divert to BHM. The airplane was in radar and radio contact with BHM terminal radar approach control, and subsequently the BHM control tower. The pilot was cleared for the instrument landing system (ILS) Runway 24 approach at BHM, which he acknowledged. The airplane initially intercepted the localizer for the approach, but did not intercept the glideslope. The airplane then proceeded left of course, above glideslope, followed by a continued left deviation and descent below the glideslope. The tower controller asked the pilot if he was still on the localizer course and the pilot replied negative. The tower controller then provided heading and altitude instructions in an attempt to guide the pilot onto a missed approach. The pilot acknowledged the heading instruction, but failed to turn to the assigned heading or climb to the assigned altitude. No further communications were received from the accident airplane and radar contact was lost. The last radar target was recorded at 1846:08, with an associated altitude of 1,700 feet mean sea level (msl). PERSONNEL INFORMATION The pilot, age 59, held a private pilot certificate, with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane. His most recent FAA third-class medical certificate was issued on December 30, 2009. At that time, the pilot reported a total flight experience of 1,500 hours. The pilot's logbook was not recovered and a determination of his flight experience in actual instrument conditions could not be made. According to a flight instructor, the pilot had owned the accident airplane for about 6 months and had 80 to 90 hours "in Barons." The pilot wanted to complete an instrument proficiency check and become more familiar with his airplane's avionics. Specifically, the pilot wanted to practice using his Garmin 530 global positioning system receiver. The flight instructor provided about 20 hours of instruction to the pilot on December 11 and 12, 2010. The flight instructor stated that at the conclusion of the instruction, the pilot was proficient. The instruction included many instrument approaches and missed approach procedures. Additionally, the flight instructor concentrated on "attitude flying," which was not the pilot's strongest skill. AIRCRAFT INFORMATION The six-seat, low-wing, pressurized, retractable-gear airplane, serial number TJ-387, was manufactured in 1982. It was powered by two Continental TSIO-520, 325-horsepower engines, equipped with McCauley propellers. According to the airplane's maintenance logbooks, its most recent annual inspection was completed on October 1, 2010. At that time, the airplane had accumulated 3,285.2 total hours of operation, and the engines had accumulated 601.3 hours of operation since major overhaul. The airplane was also equipped with a Garmin 530 global positioning system, which was destroyed during impact. METEOROLOGICAL INFORMATION The pilot telephoned flight service at 1204 and received a standard briefing for an IFR flight to EET, with BHM as an intended alternate. The forecast for EET and BHM were the same for after 1600, which included overcast ceiling 1,000 feet and 6 miles visibility in mist. The reported weather at BHM, elevation 650 feet msl, at 1840, was: wind from 300 degrees at 3 knots; visibility 2 miles in drizzle and mist; ceiling 300 feet overcast; temperature 10 degrees Celsius; dew point 9 degrees Celsius; altimeter 29.82 inches of mercury. WRECKAGE AND IMPACT INFORMATION The wreckage was located in a residential area, resting near a street curb, about 1/2 mile south of the runway 24 threshold. The wreckage was examined at the accident site and all major components of the airplane were accounted for at the scene. No debris path was observed, nor was there any damage to trees surrounding the accident side. The main wreckage came to rest upright, oriented about a 225-degree heading, with the empennage canted over into the cabin area. The wings remained attached to the fuselage and the engines remained attached to the wings. The leading edge of the left wing exhibited crush damage, the left flap was partially separated, and the left aileron was in an approximate neutral position. The right flap was partially separated from the right wing. The right aileron remained attached, was buckled, and found in an approximate neutral position. The empennage sustained little damage, with the exception of thermal damage to the leading edges. The vertical stabilizer, horizontal stabilizer, rudder, and elevator remained intact. The cabin and cockpit area were consumed by fire. Flight control continuity was confirmed from the rudder, elevator, and elevator trim to the cockpit area. Continuity was also confirmed from the ailerons to the cockpit area. Measurement of the elevator trim control revealed a 6-degree tab down (nose-up) trim. The landing gear and flaps were found retracted. The left engine fuel valve was found off-scale, and the right engine fuel valve was found in the crossfeed position; however, the cables between the valves and the control handles had been pulled from the valves during the impact sequence. An attitude indicator, airspeed indicator, altimeter, vertical speed indicator, load meter, fuel quantity indicator, and cabin pressure indicator were the only instruments recovered, and they sustained fire damage. The faceplate was missing from the attitude indicator and disassembly of the unit revealed the gyro and gyro housing exhibited rotational scoring. The respective needles were missing from the airspeed indicator, altimeter, and vertical speed indicator. The altimeter displayed 29.80 in the Kollsman window. Both engines were removed from the airframe for inspection. The left propeller hub had separated from the left engine during impact, and all three propeller blades separated from the hub. One propeller blade exhibited s-bending, chordwise scratching, and tip curling. The other two propeller blades were later recovered from the scene by an environmental crew. The Nos. 1, 2, and 3 top spark plugs, and the Nos. 1, 3, 4, and 5 bottom spark plugs were removed from the left engine. Examination of the spark plugs revealed their electrodes were intact and deposits were light gray in color. The No. 6 cylinder sustained impact damage and the crankshaft could not be rotated by hand. The oil sump was then removed to facilitate borescope access to the crankshaft. A borescope examination of the camshaft, crankshaft, and cylinders did not reveal any catastrophic failures. The oil filter was disassembled and no metallic contamination was observed. The turbocharger impeller blade could be rotated freely by hand. The engine driven fuel pump drive shaft remained intact. The throttle and mixture linkage remained attached to the fuel servo. Both magnetos and the vacuum pump were not recovered and presumed destroyed; however, the vacuum pump drive shaft remained intact. The right propeller hub separated from the right engine and two of the blades separated from the hub. One of the separated blades exhibited s-bending, chordwise scratching, and leading edge gouging. The other two blades exhibited minor damage. Due to impact damage, the crankshaft rotation was limited to approximately 30 degrees. Camshaft and crankshaft continuity to the rear accessory section was confirmed. All pistons moved during rotation, as did the magneto drives and oil pump drive. All spark plugs were removed from the engine, except for the No. 3 top and the Nos. 4 and 6 bottom. The spark plug electrodes were intact and light gray in color. The oil filter was disassembled and no metallic contamination was observed. The turbocharger impeller blade could be rotated freely by hand. The engine driven fuel pump drive shaft remained intact, as did the vacuum pump drive shaft. The vacuum pump was removed from the engine and disassembled for inspection; the vanes remained intact and rotational scoring was observed on the housing. The throttle and mixture linkage remained attached to the fuel servo. Both magnetos produced spark at all leads when rotated with a drill. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot on January 7, 2011, by the Jefferson County Medical Examiner's Office, Birmingham, Alabama. Toxicological testing was performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma. Review of the toxicology report revealed" "...0.0178 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Lung Tetrahydrocannabinol (Marihuana) NOT detected in Kidney 0.0522 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Liver 0.0267 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Kidney Tetrahydrocannabinol Carboxylic Acid (Marihuana) NOT detected in Lung..." ADDITIONAL INFORMATION Review of FAA Advisory Circular 60-4A revealed: "The attitude of an aircraft is generally determined by reference to the natural horizon or other visual references with the surface, if neither horizon nor surface references exist, the attitude of an aircraft must be determined by artificial means from the flight instruments. However, during periods of low visibility, the supporting senses sometimes conflict with what is seen, when this happens, a pilot is particularly vulnerable to disorientation. The degree of disorientation may vary considerably with individual pilots, Spatial disorientation to a pilot means simply the inability to tell which way is up."
The pilot's failure to maintain control of the airplane during an instrument approach due to spatial disorientation.
Source: NTSB Aviation Accident Database
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