# NTSB BFO94FA032: Beech BE-58, N555AC, Newtown, OH, January 27, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 26, 1994, 22:02 local (Jan 27, 1994, 03:02 UTC) - Place: Newtown, OH - Coordinates: 39.110092, -84.329811 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.1101&lon=-84.3298&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report October 19, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 8837 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=BFO94FA032 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8837/pdf - Page: https://openairdocs.org/ntsb/BFO94FA032 ## Probable cause FAILURE OF THE PILOT TO MAINTAIN CONTROL OF THE AIRCRAFT AFTER BECOMING SPATIALLY DISORIENTATED IN NIGHT INSTRUMENT METEOROLOGICAL CONDITIONS (IMC). FACTORS RELATED TO THE ACCIDENT WERE: THE PILOT'S LACK OF EXPERIENCE IN THE TYPE OF OPERATION, HIS LACK OF RECENT INSTRUMENT EXPERIENCE, AND INADEQUATE SURVEILLANCE OF THE OPERATION BY THE CHIEF PILOT/COMPANY MANAGEMENT. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, climb - to cruise - light condition - dark night - weather condition - clouds - aircraft control - not maintained, pilot in command (cause) - spatial disorientation, pilot in command (cause) - lack of total experience in type operation, pilot in command (contributing factor) - lack of recent instrument time, pilot in command (contributing factor) - inadequate surveillance of operation, company/operator mgmt (contributing factor) - In flight collision with object, descent - uncontrolled ## Analysis THE PILOT PREFLIGHTED THE AIRPLANE & RECEIVED A WEATHER BRIEFING FOR A NIGHT CARGO FLIGHT IN INSTRUMENT CONDITIONS. NO ABNORMALITIES WERE REPORTED BY THE PILOT, OR BY WITNESSES WHO SPOKE WITH HIM. HE TOOK OFF ON RUNWAY 6 & CONTACTED APPROACH CONTROL. AFTER ENTERING CLOUDS DURING THE INITIAL CLIMB, THE AIRPLANE TURNED FROM THE INTENDED COURSE & ENTERED A RAPID DESCENT. IT CRASHED ON A HEADING OF 290 DEGREES, WHILE IN A RIGHT WING LOW ATTITUDE. NO PREIMPACT MECHANICAL DEFICIENCIES WERE FOUND WITH THE AIRFRAME, ENGINES, OR SYSTEMS. THE PILOT HAD LOGGED 31.5 HOURS OF MULTIENGINE FLIGHT TIME & 65.7 HOURS OF INSTRUMENT FLIGHT TIME AS OF ABOUT 3 MONTHS BEFORE THE ACCIDENT; NO PILOT LOGBOOK ENTRIES WERE LOCATED TO VERIFY SUBSEQUENT FLIGHT TIME. THE CHIEF PILOT WAS A 'GOOD FRIEND' OF THE PILOT. HE HAD DOCUMENTED FLIGHT EXPERIENCE OF THE ACCIDENT PILOT, WHICH WAS NOT CONSISTENT WITH THE PILOT'S PERSONAL LOGBOOK OR VERBAL COMMENTS BY THE ACCIDENT PILOT, 6 DAYS BEFORE THE ACCIDENT. REPORTEDLY, THIS WAS THE PILOT'S 4TH OR 5TH SINGLE-PILOT PART 135 FLIGHT. ## Factual narrative HISTORY OF FLIGHT On January 26, 1994, at 2202 hours eastern standard time, N555AC, a Beech BE-58, operating as Flight 203 by Cape Central Airways, Inc., collided with terrain in Newtown, Ohio, following an uncontrolled descent immediately after climbout. The airplane was destroyed. The certificated commercial pilot, the sole occupant, was fatally injured. Instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed. The airplane had departed Lunken Field, Cincinnati, about 2158 hours, and was en route to Cleveland, Ohio. The cargo flight was conducted under 14 CFR 135. The purpose of the flight was to deliver cancelled bank checks from Cincinnati to Cleveland, Ohio. The accident occurred during the first leg of a scheduled night cargo run to Cleveland and return. According to witnesses, the pilot had slept on the day accident and awoke about 2000 hours. About 2100 hours, the pilot arrived at the Lunken Field to pre-flight the airplane. A line service technician stated that the pilot spent about 15 minutes pre-flighting the airplane. The pilot appeared to be "feeling fine" and was "behaving normally." The pilot did not indicate that he was having problems with the airplane, and he did not request any services from the technician. At 2107 hours, the pilot contacted the Dayton Automated Flight Service Station by telephone and received a weather briefing. The briefing was concluded at 2120 hours. About 2150 hours, a courier who delivered cancelled bank checks arrived to load the airplane. The courier's observations of the pilot and the airplane were consistent with the line service technician's observations. According to the FAA air traffic control (ATC) voice recordings and recorded radar data (attached), the pilot received taxi instructions to runway 6 and an IFR clearance to Burke Lakefront Airport in Cleveland, Ohio, at 2154 hours. At 2158 hours, the pilot was cleared for takeoff. At 2159:30 the pilot contacted Cincinnati Departure control and reported he was flying "...runway heading climbing to [2,500 feet]." Departure controller stated "radar contact climb and maintain [4,000 feet]." The pilot acknowledged. At 2200:00 hours, the airplane was at an altitude of 2,100 feet mean sea level (msl), and was turning right from a heading of 049 degrees magnetic at a ground speed of 101 knots. The pilot was asked to "say on course heading" and the pilot responded "about [040 degrees] or so." At 2200:08 hours, the pilot was told "to resume own navigation climb and maintain nine thousand." The pilot acknowledged. At the time the pilot acknowledged, the airplane was climbing from an altitude of 2,300 feet msl, heading 044 degrees magnetic. During the next 28 seconds, the airplane climbed at a rate of 600 feet per second to an altitude of 2,600 feet msl and began to turn to the right from a heading of 044 degrees to 058 degrees, opposite the direction of the pilot's intended course. During the next 14 seconds, from 2200:40 hours to 2200:54 hours, the airplane descended to 1,700 feet msl at a rate of 3,857 feet per minute. The airplane's heading deviated 52 degrees to the right and the ground speed increased 10 knots. At 2200:59 hours, radar contact was lost. At 2203:00 hours the controller attempted to contact the pilot; the pilot never responded. About 2203 hours, a phone call was received by the FAA reporting that an airplane had crashed near Newtown. No distress calls from the pilot were recorded during the entire flight. A resident was in her home, located about 1/8 mile from the accident site, when the accident occurred. She stated that she heard the airplane flying "low" over her house. She also stated: It did not sound like it was having engine problems. The engines sounded smooth at first for about 15-20 seconds. Then, the engine noise sounded like it decreased in power, but smoothly and quickly, not like it suddenly died. This lasted about 2 seconds. Then the engines revved up to full throttle. This lasted about 2 to 3 seconds. Then I heard a loud thud - engine noise went silent. I did not hear any popping and sputtering. The airplane wreckage was found about three miles from the departure airport on the extended centerline of runway 6. The accident occurred during the hours of darkness about 39 degrees 06.20 minutes North, and 84 degrees 25.12 minutes West. PERSONNEL INFORMATION The pilot, age 40, possessed an FAA Commercial Pilot certificate and Instrument rating issued July 19, 1990. The certificate contained ratings and limitations of airplane single and multiengine land. The pilot also possessed an FAA Certified Flight Instructor certificate with ratings for airplane single engine and instrument airplane. His first class medical certificate, dated August 9, 1993, contained the limitation that he "must wear corrective lenses for distant and near vision." Company training records (attached) indicate that the pilot began initial ground and flight training with Cape Central Airways in December 1993. According to the records, the pilot satisfactorily completed 7.7 hours of company instuction from the chief pilot during six flights. The pilot successfully completed an airmen competency /proficiency check flight on January 19, 1994. The check flight was administered by the chief pilot. The chief pilot stated that the flight was conducted at night in instrument conditions. He stated the flight included a localizer backcourse approach, an instrument landing system approach, a VOR approach, and an NDB approach. The duration listed on the check ride form was 1.2 hours with all items, including air work, satisfactorily completed. The chief pilot stated that he was a "good friend" of the pilot. The pilot worked for him as a single-engine flight instructor at Acme Aviation, Harrison Field, Ohio. The accident pilot was also employed by BlesAir, Miami University Airport, Oxford, Ohio, for about 2 to 2 1/2 years prior to his employment with Cape Central Airways. According to the chief pilot, the accident pilot acted as pilot-in-command on the "Part 91 legs" during Cape Central flights. These flights were conducted in a Piper Aztec, Beech Baron, and Beech 18. He flew with the chief pilot and received dual instruction. When asked how many flights the accident pilot flew during this time, the chief pilot stated that he flew "about half" of the 16 flights the company would schedule a month for the cargo run. The chief pilot could not provide documentation to verify the instruction. The chief pilot provided copies of the accident pilot's personal logbook to the NTSB; however, he stated that he did not know where copies of the last three months of entries from the logbook were located. The chief pilot also stated that recent fight manifest information leading up to the time of the accident was found in a metal binder at the accident site, and that he gave the information to FAA inspector. The FAA inspector stated that she did not receive the information. The following pilot flight experience (in hours) was extracted from the pilot's personal logbook, airline resume, and NTSB pilot/operator report: PILOT LOGBOOK AIRLINE RESUME NTSB Form 6120.1/2 Date: 10/5/93 1/19/94 1/28/94 Total Time: 1517.4 1700 1750 SEL: 1480 1400 1550 MEL: 31.5 200 200 X-Country: 267.5 575 --- Total Night: 100.5 400 200 Night X-C: 23.7 300 --- Instrument: 65.7 (total) BLANK 155 The resume and NTSB form 6120.1/2 were both completed and verified by the chief p ## Aircraft - Registration: [N555AC](https://openairdocs.org/deregistered/N555AC-2007-05-19), registration cancelled 2007-05-19, S/N TH-12, built 1970 (OpenAirDocs) - Reported make and model: BEECH BE-58 - Registry model: [Beech 58](https://openairdocs.org/model/beech-58) (registry code 1152740) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TH-12 - Airframe hours: 6225 - Engines: CONTINENTAL IO-520-C 285 horsepower reciprocating - Damage: Destroyed - Flight: Part 135 - Operator: Cape Central Airways - Registered owner: River City Aviation, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 14, 1993, 308 hours before - Departed: LUK, CINCINATTI, OH - Destination: BKL, CLEVELAND, OH - Flight plan: IFR - Airport: LUK, Lunken, runway 6, 5,128 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 1,750 total, 125 in this make and model, 1,675 as pilot in command, 125 in the last 90 days, 50 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 30° at 11 knots - Visibility: 8 statute miles - Lowest ceiling: 1,700 ft overcast - Temperature: 30 °F, dew point 25 °F - Altimeter: 30.00 inHg - Observed at: LUK, 3 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19940126000889A](https://openairdocs.org/incident/19940126000889A), Jan 26, 1994: Beech 58, Cincinnati, OH, Destroyed, 1 fatal. Lost control on climb to cruise. Dark night in clouds. Indicates spatial disorientation. Descended into trees. From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.