Buckeye, AZ, USA
N13AR
BEECH E35
The flight instructor and student pilot departed the airport where the airplane was based and proceeded to another airport, flying a flight profile consistent with flight training. They flew one straight-in approach to a low approach over the runway, about 200 ft above ground level (AGL). Following the low approach, the airplane made a right turn to downwind about midway down the runway. The airplane did not climb during the turn or after it was established on downwind. It remained 200-300 ft AGL and maintained airspeed at or near the 45° bank no-flap stall speed. The airplane then angled towards the extended runway centerline and began a turn to final shortly after passing abeam the runway threshold. The airplane subsequently impacted terrain in the turn and short of the runway. A postimpact fire ensued and the airplane was destroyed. There were no witnesses to the accident. The airplane impacted terrain in a near-vertical and left-wing-low attitude, consistent with impact following a stall. Postaccident examination of the wreckage and engine revealed no preimpact anomalies and damage to the propeller blades was consistent with the engine producing power at the time of impact. The flaps were found in the retracted position, contrary to normal landing procedures that specify the flaps should be extended. The student pilot had heart disease and had used a medication that increased his risk of having a sudden impairing or incapacitating cardiac event such as arrhythmia or heart attack. There is no autopsy evidence that such an event occurred, although such an event does not reliably leave autopsy evidence if it occurs just before death. Operational evidence in this case makes a sudden medical event involving the student pilot unlikely. Had such an event occurred with the student pilot flying, the flight instructor would have been available to assist in maintaining airplane control. Additionally, the airplane’s flight path prior to the accident indicates the airplane was being flown in a controlled manner. Due to the limitations of the instructor’s toxicological testing, the results of that testing cannot be reliably interpreted. Thus, there is insufficient toxicological evidence to determine whether the instructor had used any substances that were potentially impairing or indicative of potentially impairing underlying conditions. The airplane was flown in a non-standard traffic pattern at an unusually low altitude that positioned the airplane closer to the runway than normal during the final turn. Additionally, the airplane flaps were found in the retracted position. It could not be determined why the non-standard traffic pattern was flown or why the flaps were retracted, but both conditions increased the susceptibility of an accelerated stall during the turn to final. It was not determined which pilot was manipulating the controls at the time of the accident, but the evidence indicates the pilot flying maneuvered the airplane such that an accelerated stall occurred. The flight instructor was responsible for the safe operation of the airplane, but he did not ensure proper airspeed or bank control during the turn to final.
HISTORY OF FLIGHTOn June 18, 2022, at 0655 mountain standard time, a Beech E-35, N13AR, was destroyed when it was involved in an accident near Buckeye, Arizona. The student pilot and flight instructor were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. A review of the automated dependent surveillance-broadcast (ADS-B) flight data revealed that the airplane departed from the Glendale Municipal Airport (GEU), Glendale, Arizona, its home base, at approximately 0625. Following a normal takeoff from runway 19, the pilot conducted maneuvers predominantly to the south before altering his course westward towards Buckeye Municipal Airport (BKX). About 20 minutes later, the airplane passed to the south of BKX, subsequently executing a right turn to adopt a northward heading. Approximately 5 miles north of BKX, the airplane initiated a descending 270° left turn, followed by a right turn as it continued on a southbound trajectory indicative of a direct approach towards runway 17 at BKX (Figure 1). The airplane executed a low approach, reaching an altitude of approximately 200 feet above ground level (AGL) before initiating a level right turn near the midpoint of runway 17. The airplane proceeded beyond a parallel runway heading toward the downwind leg and then began angling toward runway 17, maintaining an altitude of about 200 feet AGL and a speed between 63-68 knots. The last recorded ADS-B data point occurred at 0654, at which point it recorded the airplane was approximately 0.43 miles west-northwest from the threshold of runway 17 (Figure 2). The airport (BKX) was equipped with a VirTower traffic monitoring system. An image of the airplane’s flight path in the traffic pattern was recovered that mostly mirrored the flight path generated by the ADS-B data (Figure 3). The VirTower flight path continued past the last recorded ADS-B point and showed the airplane made a right turn and maintained a heading of about 030° before the flight track ended near the accident location bearing 313° and .22 miles from the approach end of runway 17. A postimpact fire occurred that destroyed the airplane. There were no witnesses to the accident and there were no recorded communications from the airplane while it operated in the BKX traffic pattern. Figure 1 – Traffic Pattern Flight Path Figure 2 – Final Flight Path Figure 3 – Traffic Pattern Flight Path (VirTower Generated) PERSONNEL INFORMATIONThe flight instructor’s logbooks were not located during the investigation and his experience in the make and model of aircraft could not be determined. The student pilot’s logbook contained only one entry indicating the student pilot had operated the airplane prior to the accident. The entry stated the student pilot and the flight instructor attempted to fly together in the accident airplane on June 11, 2022. The entry indicated the student pilot logged 0.5 hours of dual instruction received. The entry also stated “Flight with intention of taking off, lost coms holding short.” The entry was signed by the flight instructor. AIRCRAFT INFORMATIONThe student pilot purchased the airplane January 25, 2019. The airplane was equipped with a dual yoke. AIRPORT INFORMATIONThe student pilot purchased the airplane January 25, 2019. The airplane was equipped with a dual yoke. WRECKAGE AND IMPACT INFORMATIONThe airplane impacted flat, sparsely vegetated desert terrain. Impact marks on the ground were consistent with the airplane hitting the ground in a nose- and left-wing-low attitude. A propeller cut mark was observed in the dirt near the engine impact point. Postimpact fire consumed most of the airplane fuselage, cockpit, and inboard portions of the wings. Both wing leading edges exhibited aft crushing damage perpendicular to the leading edge, with the left wing being crushed further aft. The fuselage and cockpit from the firewall aft to about two feet forward of the empennage was consumed by postimpact fire. Cockpit instrumentation, switches, and controls were mostly destroyed by fire. Flight control continuity was verified to all control surfaces from the cockpit. The left and right flaps were in the retracted position and the position of the flap control handle could not be determined. All landing gear were in the extended position. Both propeller blades exhibited leading edge polishing and chordwise scratches. One blade was bent aft about 45° near the midpoint of the blade and was loose on the hub. The second blade was bent aft about 80° about 1/3 the length of the blade outward from the hub. Engine continuity, cylinder compression, and valvetrain continuity were verified by rotating the propeller by hand. The top spark plugs were removed and exhibited normal burn signatures. No preimpact mechanical anomalies were noted with the engine or airframe during post-accident examination. ADDITIONAL INFORMATIONThe Federal Aviation Administration Airplane Flying Handbook (FAA-H-8083-3C) states the following regarding standard airport traffic patterns: - The traffic pattern altitude is usually 1,000 feet above the elevation of the airport surface. - The downwind leg is a course flown parallel to the landing runway, but in a direction opposite to the intended landing direction. This leg is flown approximately 1/2 to 1 mile out from the landing runway and at the specified traffic pattern altitude. - Pattern altitude is maintained until at least abeam the approach end of the landing runway. At this point, the pilot should reduce power and begin a descent. The pilot should continue the downwind leg past a point abeam the approach end of the runway to a point approximately 45° from the approach end of the runway, and make a medium-bank turn onto the base leg. Pilots should consider tailwinds and not descend too much on the downwind in order to have sufficient altitude to continue the descent on the base leg. - The base leg is the transitional part of the traffic pattern between the downwind leg and the final approach leg. Depending on the wind condition, the pilot should establish the base leg at a sufficient distance from the approach end of the landing runway to permit a gradual descent to the intended touchdown point. While on the base leg, the ground track of the airplane is perpendicular to the extended centerline of the landing runway. Stall Speeds The airplane’s gross weight at the time of the accident was not determined. Estimated gross weight using a generic empty weight for an E-35 airplane (1791 lbs), 17 gallons of fuel (102 lbs), no baggage, and the reported weights of both occupants (463 lbs) resulted in a gross weight estimate between 2,300-2,400 pounds. According the aircraft performance charts, the no-flap stall speeds (indicated airspeed) for the airplane are as follows: 2300 lbs 2400 lbs Level 54 kts 55 kts 30° Bank 58 kts 59 kts 45° Bank 65 kts 66 kts The flap DOWN stall speeds (indicated airspeed) for the airplane are as follows: 2300 lbs 2400 lbs Level 46 47 30° Bank 50 51 45° Bank 55 56 The pilot’s operating handbook (POH) Before Landing checklist, step 7, states “Flaps – Down.” MEDICAL AND PATHOLOGICAL INFORMATIONStudent Pilot The Maricopa County Office of the Medical Examiner performed the student pilot’s autopsy. According to the autopsy report, his cause of death was blunt force injuries and his manner of death was accident. His heart was described as enlarged, with a slightly dilated shape. His heart weight was 625 grams (upper limit of normal is roughly 570 grams for a male of body weight 270 pounds), his left cardiac ventricular wall thickness was 1.5 cm (normal is roughly 0.9 cm to 1.6 cm), his right cardiac ventricular wall thickness was 0.3 cm (normal is roughly 0.2 cm to 0.6 cm), and his cardiac intraventricular septal thickness was 1.4 cm (normal is roughly 0.9 to 1.8 cm). His right coronary artery had up to 25% narrowing by plaque. Visual examination of his heart was otherwise unremarkable for natural disease. The remainder of his autopsy did not identify other significant natural disease. His reported weight at his last flight physical dated January 31, 2022 was 270 pounds. The FAA Forensic Sciences laboratory performed toxicological testing of postmortem specimens from the student pilot. Phentermine was detected in cavity blood and urine. Phentermine is a prescription weight loss medication. It is the most frequently prescribed medication for weight loss in the United States. It is a Schedule IV controlled substance under federal law, with some potential for abuse. It may sometimes be associated with adverse cardiovascular effects including increased blood pressure, rapid or irregular heartbeat, or heart attack. Side effects of phentermine may include insomnia, nervousness, and dizziness. Uncommonly, more extreme side effects such as psychosis may occur. The drug typically carries a warning that it may impair the ability to engage in potentially hazardous activities such as operating machinery or driving a motor vehicle. The FAA considers phentermine to be a “do not issue/do not fly” medication. Flight Instructor The Maricopa County Office of the Medical Examiner performed the pilot’s autopsy. According to the pilot’s autopsy report, his cause of death was blunt force and thermal injuries, and his manner of death was accident. His autopsy did not identify any significant natural disease. His reported weight at his last flight physical dated December 13, 2019, was 193 pounds. The flight instructor initially survived the accident and was transported to a hospital for treatment. During treatment he received blood and plasma under massive transfusion protocols. Because the pilot received a large amount of donated blood products before his death, toxicological results in his postmortem specimens were not considered useful for this investigation, as donated blood may contain drugs. The screening routinely performed on donated blood does not test for drugs.
The pilots’ failure to climb and complete a normal traffic pattern after making a low approach and their failure to extend the flaps for reasons that could not be determined, and the flight instructor’s failure to ensure adequate airspeed and bank control during the turn to final approach, which resulted in an accelerated stall.
Source: NTSB Aviation Accident Database
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