Aviation Accident Summaries

Aviation Accident Summary CEN13FA137

Mangum, OK, USA

Aircraft #1

N143E

BEECH 95-B55 (T42A)

Analysis

The pilot conducted a taxi test down the runway, stopped to pick up two passengers, and then departed on the local flight in the twin-engine airplane. Two witnesses reported hearing the airplane, which made them notice it flying toward them. They stated that it sounded like it "sputtered" and that they then saw the airplane nose dive into a spin. They indicated that the airplane appeared to flatten out before it collided with terrain. Review of radar data revealed that the airplane conducted various maneuvers before the accident, including a 360-degree left turn about 5 to 6 miles from the airport. The track then turned east before turning north away from the airport. The radar data indicated that the airplane slowed as it turned north. Only one of the radar plots indicated the airplane's altitude, and it indicated that it was at 3,600 feet (about 2,000 feet above ground level [agl]).  A mechanic reported that he had performed an annual inspection on the airplane before the airplane's departure; however, the inspection was not noted in the airplane's maintenance records. The last recorded annual inspection was conducted about 17 months before the accident. Further, the postaccident examination revealed that the engines were missing their respective dataplates and that the altimeter and static system test was last conducted 25 months before the accident. Despite these discrepancies, examination of the airplane and engines did not reveal any abnormalities that would have prevented normal operation. On the basis of the evidence, the airplane slowed and then entered a  stall/spin. However, it could not be determined whether the pilot was performing an intentional maneuver or if there was a loss of engine power. According to the airplane's Pilot's Operating Handbook, stalls should be recovered no lower than 3,000 feet agl. A review of the pilot's logbooks revealed that he had last flown a multiengine airplane about 7 months before the accident and that he had flown only about 30 hours in multiengine airplanes in the 2 years before the accident. The pilot's last flight review, which was conducted in the accident airplane, occurred about 27 months before the accident. The pilot's toxicological report noted the presence of a therapeutic level of amitriptyline, an antidepressant, which was not declared in his medical history. It could not be determined whether the pilot was impaired by the amitriptyline or the underlying condition for which it was prescribed at the time of the accident.

Factual Information

HISTORY OF FLIGHTOn January 19, 2013, about 1700 central standard time, a Beechcraft Baron 95-B55, airplane, N143E, impacted terrain near Mangum, Oklahoma. The commercial rated pilot and two passengers were fatally injured and the airplane was substantially damaged. The airplane was registered to and operated by JS Leasing, LLC, Mangum, Oklahoma, under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed which operated without a flight plan. The local flight originated from the Scott Field Airport (2K4), Mangum, Oklahoma. According to persons familiar with the flight, the airplane had its annual maintenance inspection completed prior to the flight. They reported that the pilot started the airplane and did a taxi test down the runway, then stopped and picked up the two passengers before departing. Witnesses reported hearing the sound of an airplane, so they turned and watched the airplane. They added that it sounded like the airplane "sputtered," before it nosed dived into a spin, which appeared to flatten out before the airplane collided with the ground. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with ratings for airplane, single-engine and multiengine land, and instrument-airplane. A third-class Federal Aviation Administration (FAA) medical was issued on November 20, 2012 with the restriction of "holder shall possess glasses for near/intermediate vision". A review of the pilot's logbook revealed that he had recorded a total of 2,170.1 hours, with 919. 3 hours in single-engine airplanes and 1,170.5 in multiengine airplanes. For calendar year 2011 he had 1.9 hours in single-engine and 16.0 hours in multiengine airplanes; for calendar year 2012 he had 7.2 hours in single-engine airplane and 14.4 hours in multiengine airplane; which was in the accident airplane. His last recorded flight in the accident airplane was on June 1, 2012, and last logbook entry was on January 12, 2013 in a single engine airplane. According to the logbook, the pilot's last flight review was on September 21, 2010, which was conducted in the accident airplane. The right seat passenger held a private pilot certificate with ratings for airplane single-engine land and flight engineer (turbojet). Additionally, he held a mechanic certificate, with airframe and powerplant ratings. The passenger was issued a third class medical certificate on March 6, 2012, with the limitation; "must wear corrective lenses for near and distant vision". At the date of the application, the passenger reported his flight experience as 54 total flight hours with 5 hours in last six months. AIRCRAFT INFORMATION The Beechcraft B55, Baron, is a twin-engine airplane powered by two Continental IO-470 reciprocating engines. The airplane is typically configured for four to six-seats including pilots, has retractable landing gear and flaps, and full-feathering propellers. A review of the airplane's maintenance records revealed that the recent annual inspection, which was reported to have been completed on the day of the accident flight, had not been entered into the airplane's paper maintenance log books. The last recorded annual inspection was done on August 5, 2011 with a Hobbs time of 5193.9 hours. In addition, the airplane's altimeter and static system were last tested on December 7, 2010. METEOROLOGICAL INFORMATION At 1655, the automated weather observation facility located at Altus Air Force Base, Altus, Oklahoma, located about 30 miles southeast of the accident site, reported calm wind, visibility 10 miles, a clear sky, temperature 61 Fahrenheit (F), dew point 35 F, and a barometric pressure of 30.12 inches of mercury. At 1915, the automated weather observation facility located at Altus/Quartz Mountain Regional Airport Altus, Oklahoma, located about 25 miles southeast of the accident site, reported calm wind, visibility 10 miles, a clear sky, temperature 50 Fahrenheit (F), dew point 34 F, and a barometric pressure of 30.18 inches of mercury. COMMUNICATIONS and RADAR INFORMATION Scott Field Airport (2K4) is a non-towered airport and the pilot was not in communication with air traffic control; there were no reported distress calls from the pilot. A review of radar information revealed a radar track consistent with the accident airplane leaving the Mangum airport about 1644. The track heads north-northwest towards the Sayre Municipal Airport (3O4), located about 18 miles away. The radar track disappears as it nears 3O4, then reappears with the airplane heading south. About 5-6 miles from 2K4, the track depict the airplane performed a large, 360 degree, left turn, before resuming the southward heading. The track then turns east, before a turn to the north away from 2K4. The radar also indicated that the airplane slowed down, as it turned northward. The track ends near the accident site at 1701. Only one of the radar plots showed the airplane's altitude; 3,600 feet (approximately 2,000 feet above ground level), otherwise the airplane's altitude (mode C) was not received by radar. WRECKAGE AND IMPACT INFORMATION The National Transportation Safety Board and an inspector from the Federal Aviation Administration (FAA) examined the airplane wreckage on site. The airplane came to rest upright in open ranch land approximately five and a half miles northwest of 2K4. The airplane remained relatively intact; both propellers had separated and were approximately 3 feet in front of their respective engines. The surrounding area was absent any ground scars, consistent with the airplane impacting terrain with little forward velocity. According to the mechanic, who performed the annual, the airplane's main fuel tanks were almost full and the auxiliary tanks were full prior to departure. First responders reported fuel on site and a post-impact fire erupted when they attempted to cut the battery cable. The fire was extinguished, before it could consume the wreckage. The fuselage sat flat on the ground and had sustained heavy impact damage; the cabin top had been cut and removed by first responders. The fuselage back to the empennage had heavy bending and buckling. The instrument panel was pushed up and back slightly into the cockpit area. The empennage exhibited damage to the both sides of the horizontal stabilizer; the elevator remained attached to the stabilizer. The vertical stabilizer remained partially attached to the aft section of the fuselage; the rudder was located on the ground aft of the empennage. The rudder and trim tab were bent aft. Both wings exhibited buckling and crushing signatures; each aileron and flap remained attached to their respective wings. The flaps appeared in the retracted position and the landing gear extended. The landing gear handle on the panel was broken; however, the landing gear bellcrank was in the extended or down position. The fuel selectors received impact damage and were pointing at the auxiliary fuel tanks. The airplane's Hobb's meter read 5203.4 hours. The leading edge of the left wing received fire damage; both nacelle areas had also received slight thermal damage from the post-crash fire. The both engines remained in their respective nacelle. Both propellers were separated from their respective crankshaft flange, with the bolts being stripped from the crankshaft flanges. MEDICAL AND PATHOLOGICAL INFORMATION The Board of Medicolegal Investigations, Office of the Chief Medical Examiner, Oklahoma City, Oklahoma, conducted autopsies on the pilot and pilot rated passenger. The cause of death on both occupants was determined to be "multiple blunt force trauma". In addition to traumatic injuries, the pilot's autopsy identified thickening of the walls of the heart. The pilot had told the FAA he was being treated for high blood pressure on his last aviation medical exam. He and had been issued a third class medical certificate with a limitation for wearing corrective lenses. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology tests on the pilot. These tests were negative for carbon monoxide and ethanol. The test identified amitriptyline, nortriptyline, and nadolol in liver and amitriptyline (0.069 g/ml), nortriptyline, and nadolol in heart blood. Amitriptyline is a tricyclic antidepressant that is also used to treat a variety of chronic pain syndromes. Its therapeutic range is 0.005 ug/ml to 0.200 ug/ml and it carries an FDA warning: "may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)." Nortriptyline is the primary metabolite of amitriptyline. Nadolol is a beta-blocker used to treat hypertension. TEST AND RESEARCH The airplane wreckage was transported to a salvage facility where both engines were examined by the NTSB, FAA, and a technical representative from the engine manufacturer. Both engines were missing their respective dataplates. Continuity was established from the front of the crankshaft to the rear gear drive section of the engine, and through the valve train. Each cylinder was borescoped and produced suction and compression during a thumb test. The left magneto on the left engine had separated on impact; the other magnetos were removed from each engine and rotated. The magneto's rotated freely and produced a spark at each terminal. Both fuel screens were not plugged, but contained a small about of unidentified contaminate on the screens. The engines fuel flow divider and the engine driven fuel pumps were examined; no abnormalities were noted. The engine inspection did not reveal any abnormalities that would have prevented normal operation. ADDITIONAL INFORMATION A review of the airplane's Pilot Operating Handbook (POH) on Stall, Slow Flight and Training stated that: "Training should be accomplished under the supervision of a qualified instructor-pilot, with careful reference to the applicable sections of the FAA Practical Test Standards ….."

Probable Cause and Findings

The airplane's aerodynamic stall/spin at low altitude and subsequent impact with terrain for reasons that could not be determined during postaccident examinations. Contributing to the accident was the pilot's lack of currency/proficiency.

 

Source: NTSB Aviation Accident Database

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