# NTSB CEN13FA089: Beech 58, N4016A, Manhattan, IL, December 4, 2012 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 4, 2012, 14:38 local (20:38 UTC) - Place: Manhattan, IL - Coordinates: 41.380554, -88.008613 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.3806&lon=-88.0086&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report September 30, 2013 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Hawker Beechcraft Corporation, FAA Flight Standards, Continental Motors, Inc. - NTSB case key (mKey): 85739 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN13FA089 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/85739/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=85739 - Page: https://openairdocs.org/ntsb/CEN13FA089 ## Probable cause An in-flight loss of control and impact with terrain for reasons that could not be determined because postaccident examination did not reveal any anomalies that would have precluded normal operation. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Beech 58, 7 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=1152740), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) (defining event); cases with it: [Beech 58, 1 case](https://openairdocs.org/ntsb-events/220/sequence.md?model=1152740), [All aircraft, 780 cases](https://openairdocs.org/ntsb-events/220/sequence.md) - [Maneuvering-low-alt flying: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech 58, 19 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1152740), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot was conducting pipeline surveillance at the time of the accident. A witness reported that he observed the accident airplane in level flight about 50 feet above a nearby two-story house. Everything appeared normal at that time; however, when he looked up a few moments later, the airplane was “sideways” with the wings oriented vertically. The airplane impacted an open field. The accident site was located about 1/3 mile east-southeast of the pipeline under surveillance. The debris path was about 950 feet long, and the airframe was fragmented during the impact sequence. A postaccident examination did not reveal any anomalies consistent with a preimpact failure or malfunction. Analysis of all available information related to the accident did not reveal a definitive cause for the in-flight loss of control and impact with terrain. ## Factual narrative HISTORY OF FLIGHT On December 4, 2012, about 1438 central standard time, a Beech model 58, N4016A, impacted an open field near Manhattan, Illinois. The commercial pilot sustained fatal injuries. The airplane was substantially damaged. The aircraft was registered to and operated by Bemidji Aviation Services under the provisions of 14 Code of Federal Regulations Part 91 as a pipeline surveillance flight. Visual meteorological conditions prevailed for the flight, which was not operated on a flight plan. The flight originated from Bemidji Regional Airport (BJI) about 0915. The intended destination was Joliet Regional Airport (JOT), Joliet, Illinois, after completion of the surveillance activity. A witness reported that he observed the accident airplane in level flight, heading south at a “really low” altitude; estimating its altitude as about 50 feet above a nearby two-story house. Everything appeared normal at that time. He noted that it was not uncommon to see airplanes and helicopters flying low in that area as they conducted pipeline or power line surveillance. He went back to his work; however, when he looked up again a few moments later, the airplane was “sideways” with the wings oriented vertically. The airplane impacted an open field on a south-southeast bearing. The accident site was located about one-third mile east-southeast of the pipeline under surveillance. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with single and multi-engine land airplane, single-engine sea airplane, and instrument airplane ratings. He was issued a second class airman medical certificate on May 23, 2012, with a restriction for corrective lenses. On the application for his medical certificate, the pilot reported a total flight time of 27,000 hours, with about 40 hours flown within the preceding 6 months. He had reported a flight time of approximately 11,000 hours in Beech model 58 airplanes on a pilot qualification record dated June 10, 2011. AIRCRAFT INFORMATION The accident airplane was a 1970 Beech model 58 (Baron), serial number TH-9. It was powered by two 285-horsepower Continental IO-520-CB engines, serial numbers 831729-R (left) and 831812-R (right). The airplane was issued a normal category airworthiness certificate in February 1970. Maintenance records indicated that the most recent annual inspection was completed on May 30, 2012, at 12,413.4 hours total airframe time. The airplane had accumulated 12,549.0 hours as of the day prior to the accident. The left and right engines had accumulated 1,682.5 hours and 1,091.4 hours, respectively, as of the day prior to the accident. The left engine was installed on the accident airplane in June 2005 at 10,866.5 hours airframe time. The right engine was installed in March 2007 at 11,457.6 hours airframe time. Both engines had been remanufactured prior to being installed on the airplane. METEOROLOGICAL INFORMATION The nearest weather reporting facility was located at JOT, about 11 milesnorthwest of the accident site. At 1435, the JOT Automated Weather Observing System (AWOS) recorded conditions as: wind from 260 degrees at 10 knots; 10 miles visibility; clear sky; temperature 14 degrees Celsius; dew point -1 degrees Celsius; altimeter 30.10 inches of mercury. WRECKAGE AND IMPACT INFORMATION The airplane impacted an open field about 3-1/4 miles south-southwest of Manhattan, Illinois. Initial ground impact was about 80 feet long and oriented on an approximate bearing of 168 degrees magnetic. An impact crater about 8 feet by 3 feet by 2 feet was located at the south end of the ground scar. The right propeller assembly had separated from the engine and was located adjacent to the impact crater. The right engine separated from the wing and came to rest about 950 feet from the initial impact. The right wing separated from the fuselage at the root; it came to rest about 430 feet from the initial impact. The main wreckage consisted of portions of the fuselage and left wing, the empennage, and the left engine. The overall debris path was oriented approximately 150 degrees magnetic. The airframe nose section, forward cabin, and left wing were fragmented during the accident sequence. The upper fuselage, from the windshield to the aft cabin was separated and deformed. The cockpit/cabin area was compromised. The forward fuselage was fragmented. The aft portion of the fuselage came to rest inverted with the main wreckage. The horizontal and vertical stabilizers remained attached to the aft fuselage. The elevators and rudder remained attached to the horizontal and vertical stabilizers, respectively. Flight control system damage and cable separations appeared consistent with impact forces. The left wing was fragmented. The left aileron and flap were separated and located within the debris path. The right wing separated inboard of the engine nacelle, near the wing root. The outboard one-third of the wing was deformed upward approximately 70 degrees. The wing tip was bent downward relative to the outboard wing section. The right flap had separated and was fragmented into three main sections. Portions of the right aileron remained attached to the wing at the hinge points. Both flap actuators were positioned consistent with a zero degree deflection (flaps up). Fractures of the left and right aileron bellcranks appeared consistent with overstress failures. The nose and left main landing gear had separated from the airframe. Both were located in the debris path. The right main landing gear remained attached to the wing trunion; it was in the retracted position. The landing gear actuator/motor was in the retracted position. Examination of the left and right engines did not reveal any anomalies consistent with a preimpact failure or malfunction. The left propeller assembly remained attached to the crankshaft flange. Two propeller blades remained attached to the hub; however, the third blade had separated near the root. The separated blade segment wasrecovered from the accident site near the initial impact point. The right propeller assembly, with the crankshaft propeller flange attached, was separated from the engine. The crankshaft fracture surface features appeared consistent with overstress failure. Two propeller blades remained attached to the hub; however, the third blade had separated near the root of the blade. The separated blade segment was embedded into the ground near the initial impact point. No anomalies consistent with a preimpact failure or malfunction were observed during the postaccident examination. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy of the pilot was completed by the Will County Coroner’s Office on December 5, 2012, in Crest Hill, Illinois. The pilot’s death was attributed to injuries sustained as a result of the accident. The FAA Civil Aerospace Medical Institute toxicology testing report stated: Atenolol detected in Liver; Atenolol detected in Blood (Cavity); Atorvastatin detected in Blood (Cavity); No Carbon Monoxide detected in Blood (Cavity). The pilot had reported the use of Atenolol and Lipitor (Atorvastatin) to the FAA at the time of his most recent airman medical examination. TESTS AND RESEARCH The pilot reportedly used a laptop computer and mapping software to assist with situational awareness to the pipeline being observed. A laptop computer was recovered at the accident site. However, damage to the computer prevented recovery of any position data that might have been available. ## Aircraft - Registration: [N4016A](https://openairdocs.org/deregistered/N4016A-2013-01-17), registration cancelled 2013-01-17, S/N TH-9, built 1970 (OpenAirDocs) - Reported make and model: BEECH 58 - Registry model: [Beech 58](https://openairdocs.org/model/beech-58) (registry code 1152740) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TH-9 - Airframe hours: 12549 - Engines: CONT MOTOR IO 520 SERIES 285 horsepower reciprocating; CONT MOTOR IO-520-CB 285 horsepower reciprocating - Damage: Substantial damage - Flight: Aerial observation, Part 91 - Operator: Bemidji Aviation Services Inc. - Registered owner: Bemidji Aviation Services Inc. - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, September 21, 2012, 34 hours before - Departed: BJI, Bemidji, MN - Destination: JOT, Joliet, IL - Airport: JOT, Joliet Regional ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 74; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine land, single-engine sea; medical: class 2, with waivers/limitations; last flight review March 23, 2012; seat: left; toxicology performed; flight hours: 27,000 total, 11,000 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 260° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 57 °F, dew point 30 °F - Altimeter: 30.10 inHg - Observed at: JOT, 11 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 20121204026099A](https://openairdocs.org/incident/20121204026099A), Dec 4, 2012: Beech 58, Manhattan, IL, Destroyed, 1 fatal. Mr. Larry diffley was the pilot in command of N4016A during a pipeline mission. He departed bemidji airport, bemidji, MN (kbji) for the pipeline mission which… ## Docket (16 files) The files NTSB released with the investigation on July 31, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=85739. 6.1 MB in all. - Witness Statement (item 1, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392572&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF - On-Scene Examination Summary (item 2, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392570&FileExtension=.PDF&FileName=On-Scene%20Examination%20Summary-Master.PDF - Maintenance Inspection Record (item 3, .PDF, 499 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392673&FileExtension=.PDF&FileName=Maintenance%20Inspection%20Record-Master.PDF - Toxicological Report (item 4, .PDF, 189 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392600&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 5, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392602&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 6, .PDF, 558 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392622&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Photo 1 -- Accident Site (item 7, .PDF, 443 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392722&FileExtension=.PDF&FileName=Photo%201%20--%20Accident%20Site-Master.PDF - Photo 2 -- Initial Impact/Right Propeller (item 8, .PDF, 422 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392726&FileExtension=.PDF&FileName=Photo%202%20--%20Initial%20Impact%2FRight%20Propeller-Master.PDF - Photo 3 -- Accident Site (item 9, .PDF, 415 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392728&FileExtension=.PDF&FileName=Photo%203%20--%20Accident%20Site-Master.PDF - Photo 4 -- Accident Site (item 10, .PDF, 451 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392729&FileExtension=.PDF&FileName=Photo%204%20--%20Accident%20Site-Master.PDF - Photo 5 -- Right Wing/Main Wreckage (item 11, .PDF, 505 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392732&FileExtension=.PDF&FileName=Photo%205%20--%20Right%20Wing%2FMain%20Wreckage-Master.PDF - Photo 6 -- Main Wreckage (item 12, .PDF, 559 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392733&FileExtension=.PDF&FileName=Photo%206%20--%20Main%20Wreckage-Master.PDF - Photo 7 -- Main Wreckage (item 13, .PDF, 427 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392734&FileExtension=.PDF&FileName=Photo%207%20--%20Main%20Wreckage-Master.PDF - Photo 8 -- Main Wreckage (item 14, .PDF, 517 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392735&FileExtension=.PDF&FileName=Photo%208%20--%20Main%20Wreckage-Master.PDF - Photo 9 -- Left Engine (item 15, .PDF, 608 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392739&FileExtension=.PDF&FileName=Photo%209%20--%20Left%20Engine-Master.PDF - Photo 10 -- Right Engine (item 16, .PDF, 437 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392740&FileExtension=.PDF&FileName=Photo%2010%20--%20Right%20Engine-Master.PDF 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.