CEN12FA082

NTSB accident investigation · Beech 23 · West Milton, OH · November 24, 2011

Accident · FatalField investigationFinal report
Date
November 23, 2011, 20:43 local (Nov 24, 2011, 01:43 UTC)
Place
West Milton, OH
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N8700MBeech 23
Defining event
Maneuvering: Loss of control in flight
Weather
Instrument (IMC) · Night/dark
Status
Completed · report April 10, 2013
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration
FAA report
20111123027639A
Case key
82387

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The non-instrument-rated pilot's decision to attempt a flight into instrument meteorological conditions, which resulted in the pilot’s spatial disorientation and subsequent loss of control of the airplane.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotBeech 23: 5 casesAll aircraft: 9,295 casesProbable cause
Ceiling/visibility/precip: below VFR minimaEnvironmental issues › Conditions/weather/phenomena · Effect on operationBeech 23: 1 caseAll aircraft: 184 cases
Experience/qualifications: total instrument experiencePersonnel issues › Experience/knowledge · PilotBeech 23: 1 caseAll aircraft: 66 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The non-instrument-rated pilot was conducting the accident flight under visual flight rules without a flight plan in dark, night, instrument meteorological conditions. Radar data depicted that shortly after departure, the airplane performed a series of multi-directional turns at varying altitudes. Several witnesses observed or heard the airplane over their residences complete several turns at a low altitude. Based on the erratic flight of the airplane, the wreckage distribution, which was consistent with a high-speed impact, and the low visibility present at the time of the accident, it is likely that the pilot experienced spatial disorientation and lost control of the airplane. A postaccident examination of the airplane revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Local law enforcement officers who responded to the accident site reported the clouds were about 700 feet above ground level when they arrived at the accident site. There is no record of the accident pilot receiving an official or "unofficial" weather briefing before departure. Federal Aviation Administration guidance indicated that spatial disorientation can occur when there is no natural horizon or surface reference, such as night flight in sparsely populated areas similar to that of the accident area and conditions.

Factual narrative

HISTORY OF FLIGHT On November 23, 2011, at 2043 eastern standard time, a Beech 23 single-engine airplane, N8700M, sustained substantial damage when it impacted terrain while maneuvering near West Milton, Ohio. The non instrument-rated private pilot, who was the co-owner and operator of the airplane, sustained fatal injuries. Instrument meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 personal flight. The flight departed the Phillipsburg Airport (3I7), Phillipsburg, Ohio, at 2038, and was en route to Marion, Ohio. According to friend of the pilot, the pilot arrived at 3I7 approximately 1400. The pilot and friend spent a few hours together and the pilot prepared to depart 3I7 approximately 2030 to return home. Prior to the flight, the pilot mentioned that the cloud layer was very low and he was going to stay under the controlled airspace near 3I7. The friend noted the pilot departed 3I7 at 2038 according to the time set in her vehicle and had no further communication with the pilot. A review of the radar data showed the airplane shortly after departure from 3I7 traveling on a northeasterly heading. Approximately 1 mile from 3I7, the data depicted the airplane make a left 360-degree turn and then continue to the northeast. Shortly thereafter, the airplane entered another left 360-degree turn and then a series of sudden left and right turns. During the turns, the airplane's altitude fluctuated between 1,000 and 2,200 feet mean sea level. At 2043, radar contact was lost. A pilot-rated witness, who was located near the accident site, reported that the airplane sounded like it was very low and made 2 to 3 tight radius circles. During each turn, the engine sounded as it was running at a very high RPM as if the airplane was in a dive, then the airplane would level off before sounding like it was in another dive. On the final turn, the engine was running at a high RPM like it was in a steep dive, and then he heard an impact. The witness described the engine operation as "healthy" until the impact. Several witnesses located near the accident site heard or observed the airplane near their residences. The witnesses described the airplane as flying low near the tree tops and the engine sound was loud. The witnesses heard the engine and then it suddenly stopped. Several witnesses then called 911 and assisted rescue personnel in locating the airplane. PERSONNEL INFORMATION The pilot held a private pilot certificate with an airplane single-engine land rating. He was issued a third class medical certificate on March 11, 2001, with the limitation for corrective lenses. According to the pilot's logbook, he accumulated 306 total flight hours, 224 flight hours in the accident airplane, and 4.6 hours of simulated instrument flight time. The pilot's most recent flight review was conducted on July 3, 2011, in the accident airplane. A family member of the pilot reported the pilot was healthy and had nomedical issues. AIRCRAFT INFORMATION The airplane was a Beech 23, serial number M-484, and manufactured in 1963. It was powered by a 160-horsepower Lycoming O-320-D2B engine and equipped with a Sensenich fixed pitch propeller. The airplane was registered to the pilot on January 9, 2006. A review of the maintenance records revealed the most recent annual inspection was completed on June 20, 2011, at a total airframe time of 1,854.6 hours. METEOROLOGICAL INFORMATION At 1956, the Dayton International Airport (DAY), Dayton, Ohio, automated surface observing system (ASOS), located 8 nautical miles southeast of the accident site, reported the wind from 270 degrees at 7 knots, 8 miles visibility, sky clear, temperature 4 degrees Celsius, dew point 3 degrees Celsius, and an altimeter setting of 30.26 inches of Mercury. At 2042, the DAY ASOS reported the wind from 250 degrees at 7 knots, 6 miles visibility, mist, sky broken at 700 feet, temperature 3 degrees Celsius, dew point 3 degrees Celsius, and an altimeter setting of 30.26 inches of Mercury. Local law enforcement officers who responded to the accident site reported the clouds were approximately 700 feet above ground level when they arrived at the accident site. There is no record of the accident pilot receiving an official or "unofficial" weather briefing before departure. WRECKAGE AND IMPACT INFORMATION Postaccident examination of the airplane showed the airplane impacted in a freshly harvested corn field near a tree line. No evidence of tree strikes were noted in the accident area. Impact ground scars were noted directly underneath the leading edges of both wings and the underside of the fuselage. The engine and two-blade propeller were found embedded in the terrain approximately 3 feet in depth. Fragmented sections of the fuselage and wings were located about 25 feet forward of the main wreckage. The main wreckage consisted of the fuselage, both wings, engine, and empennage. The left wing leading edge was crushed aft and the wing skins were separated from the wing ribs and spars. The aileron and flap remained attached to the wing. The fuel tank was ruptured and fragmented. The wing tip fairing was fragmented. The landing gear was attached and bent aft. The right wing leading edge was crushed aft and the wing skins were separated from the wing ribs and spars. The aileron and flap remained attached to the wing. The fuel tank was ruptured and fragmented. The wing tip fairing was fragmented. The landing gear was attached and bent aft. The lower forward fuselage was crushed aft and partially embedded in the terrain. The upper fuselage was bent up and crushed aft. The instrument panel was fragmented and destroyed. The attitude indicator and directional gyro were disassembled to examine the gyro wheels and housings. The gyro wheels were free to move within the housings and radial scoring was noted inside the housings and on the gyro wheels. The empennage was crushed and bent. The vertical stabilizerwas partially bent and the rudder remained attached. The horizontal stabilator was intact and no damage was noted. Aileron and flap control continuity was confirmed from the cockpit control yoke to the control surfaces. Stabilator and rudder control continuity was confirmed from each control surface to the control yoke and the rudder pedals, respectively. Internal engine continuity was confirmed and compression was obtained at each cylinder during crankshaft rotation. The spark plugs exhibited signatures consistent with normal operation. The vacuum pump was disassembled; the rotor and vanes were fractured. Both propeller blades displayed s-type bending, and chordwise scratches and polishing were noted on the chambered side of the blades. MEDICAL AND PATHEOLOGICAL INFROMATION The Montgomery County Coroner's Office performed the autopsy on the pilot on November 25, 2011. The autopsy concluded that the cause of death was multiple blunt force trauma and the report listed the specific injuries. The Federal Aviation Administration’s (FAA) Civil Aerospace Medical Institute (CAMI), Oklahoma City, Oklahoma, performed toxicological tests on specimens that were collected during the autopsy. Tests for carbon monoxide and cyanide were not performed. Results were negative for volatiles, and unspecified level of Diphenhydramine was detected in the liver and kidney. ADDITIONAL INFORMATION FAA's AC (Advisory Circular) 60-4A, entitled “Pilot’s Spatial Disorientation,” states that disorientation is caused by a lack of visual reference to the natural horizon, and can be brought about by low visibility, night conditions, and reflected light from the anticollision rotating beacon. Disorientation can cause the pilot to inadvertently place the airplane in a dangerous attitude. To avoid becoming disoriented, the Advisory recommends that pilots obtain training and maintain proficiency in aircraft control by reference to instruments, to rely solely on those instrument indications, and to avoid flying in poor or deteriorating weather conditions.

Aircraft

Registration
N8700M
Reported as
Beech 23
Category
Airplane
Serial number
M-484
Airframe hours
1,855
Engine
Lycoming O-320-D2B, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
On File
Registered owner
On File
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 20, 2011
Departed
3I7 · Phillipsburg, OH
Destination
MNN · Marion, OH

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
70
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
July 3, 2011
Seat
Left
Toxicology
Performed
Flight hours
306 total · 224 in this make and model · 4 in the last 90 days

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
250° at 7 knots
Visibility
6 statute miles
Lowest ceiling
700 ft broken
Temperature
37 °F, dew point 37 °F
Altimeter
30.26 inHg
Observed at
DAY, 8 nm away

Docket · 13

The files NTSB released with the investigation on January 30, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.7 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N8700M · 1

Matched to the same aircraft by N-number and date.