# NTSB CEN17FA005: Beech D95A, N76S, Hitchcock, TX, October 4, 2016

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: October 4, 2016, 18:26 local (23:26 UTC)
- Place: Hitchcock, TX
- Coordinates: 29.273056, -95.071388 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=29.2731&lon=-95.0714&mi=10
- Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping)
- Defining event: [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240)
- Highest injury: Fatal
- Injuries: 1 fatal, 1 serious
- Status: Completed, report November 13, 2017
- Report: Approved by Office Director
- NTSB office: Central Region
- Parties: FAA Houston FSDO, Textron Aviation, Hartzell Propeller Inc, Lycoming Engines
- NTSB case key (mKey): 94140
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN17FA005
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94140/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94140
- Page: https://openairdocs.org/ntsb/CEN17FA005

## Probable cause

The flight instructor's loss of control during an aerodynamic stall demonstration, which resulted in an inadvertent spin from which he was unable to recover. Contributing to the accident was the flight instructor's lack of familiarity with the airplane's stall characteristics.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Beech D95A, 2 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1153408), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech D95A, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=1153408), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md)
- [Experience/qualifications: total experience w/ equipment](https://openairdocs.org/ntsb-findings/02031025): Personnel issues › Experience/knowledge · Instructor/check pilot (probable cause); cases with it: [Beech D95A, 1 case](https://openairdocs.org/ntsb-findings/02031025/cases.md?model=1153408), [All aircraft, 269 cases](https://openairdocs.org/ntsb-findings/02031025/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Beech D95A, 2 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1153408), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Maneuvering: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Beech D95A, 2 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=1153408), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md)
- [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech D95A, 2 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1153408), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

A flight instructor and private pilot receiving instruction departed on the accident flight to practice aerodynamic stalls in the multiengine airplane. After the accident, the pilot recalled that the instructor initiated an aerodynamic stall maneuver about 4,000 ft mean sea level, then recalled the instructor "cursing" the airplane when it would not recover from the stall. The pilot could not recall any further details of the accident flight. A witness about one 1 mile south of the accident site saw the airplane descending in a fully- developed right spin. Data retrieved from an onboard GPS unit revealed that the airplane entered a climb from about 4,000 ft, reaching a peak altitude of about 4,800 ft. The airplane then immediately entered a descent that continued until the end of the recorded data. Post-accident examination of the airplane revealed no mechanical malfunctions or anomalies that would have precluded normal operation. Review of the flight instructor's logbooks indicated that he had accumulated over 9,800 total hours of flight experience, with over 4,600 hours in multiengine airplanes; however, he had only accumulated 16 hours in the 11 years before the accident. He had logged about 11 hours in the accident airplane, of which about 6 hours were as a flight instructor, all within the previous two months. His logbooks did not indicate that he had previously practiced aerodynamic stalls in the accident airplane; therefore, he was likely unfamiliar with the airplane's stall characteristics. Following a series of fatal accidents in Beech Baron/Travel Air airplanes between 1978 and 1980, the National Transportation Safety Board issued safety recommendations to the Federal Aviation Administration, stating that these airplanes have a propensity for entering flat spins under high asymmetric power and low speed conditions; such conditions are frequently encountered during multiengine emergency (engine-out) training. It is likely that, while demonstrating aerodynamic stalls, the airplane entered a spin from which the flight instructor was unable to recover.

## Factual narrative

Following a series of fatal accidents in Beech Baron- and Travel Air-series airplanes, the National Transportation Safety Board issued Safety Recommendations A-81-49 through -53 on May 7, 1981, because of the propensity of these airplanes to enter flat spins under conditions of high asymmetric power and low speed. Training for a potential emergency, such as an engine-out condition, "may be more hazardous than the emergency itself." In 1974, the U.S. Army issued a report on the stall characteristics of the Beech T-42A, which is similar to the B55B and D95A airplanes. Section 3, page 6, of the Beech D95A Owner's Manual states: "This is a normal category airplane. Maneuvers, including spins, are prohibited." Section 4, page 9, states: "If a spin is entered inadvertently, cut the power on both engines. Apply full rudder opposite the direction of rotation and then move the elevator forward until rotation stops. When the controls are fully effective, bring the nose up smoothly to a level flight attitude. Don't pull out too abruptly." The accident airplane, serial number TD-605, was manufactured by the Beech Aircraft Corporation in 1965. It was powered by two Lycoming IO-360-B1B engines, serial numbers RL-29744-51A (left) and RL-28158-51A (right), each rated at 180 horsepower, and driving Hartzell HC-92WK-2B two-blade, all-metal, constant-speed propellers. The left engine and propeller were overhauled on February 28, 2014, due to a propeller strike. It had accumulated 2,672.1 total hours (1,042.7 hours since the previous major overhaul). According to the maintenance records, the airframe, both engines, and both propellers received a 100-hour/annual inspection on August 1, 2016. The tachometer read 2,696.1 hours, and the airframe has accumulated 4,085.2 hours at the time of the inspection. At the time of the 100-hour/annual inspection, • the left engine had accrued 2,696.1 total hours (1,066.9 hours since major overhaul). • the left propeller had accrued 4,085.2 total hours (24.0 hours since major overhaul) • the right engine had accumulated 700.7 since being factory-remanufactured on July 25, 2003, and • the right propeller had accrued 4,085.2 total hours, and 329.2 hours since major overhaul. The last altimeter, transponder, encoder, and static system checks were made on August 12, 2014. On October 4, 2016, at 1826 central daylight time, a Beech D95A airplane, N76S, was destroyed after impacting trees and terrain near Hitchcock, Texas. The flight instructor was fatally injured and the pilot receiving instruction was seriously injured. The instructional flight was operated by Bay Area Flying Club, Pearland, Texas, under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the local flight, which originated from Pearland Regional Airport (KLVJ), Pearland, Texas. According to the pilot's brother who spoke with the pilot in the hospital following the accident, thepurpose of the flight was for the flight instructor to demonstrate aerodynamic stalls. The pilot said that a stall was initiated from about 4,000 ft mean sea level (msl). The pilot then vaguely remembered the instructor "cursing" the airplane because the flight instructor was unable to recover from the stall maneuver. The pilot was unable to recall any further details of the accident. A duck hunter, located about 1 mile south of the accident site, took a cell phone video that captured the airplane descending in a fully-developed right spin. According to data retrieved from an onboard GPS unit, the airplane entered a cliumb from about 4,000 ft at 1825:23, reaching a peak altitude of about 4,800 ft about 1825:50. The airplane then entered a descent that continued until the end of the recorded data at 1826:44. PERSONNEL INFORMATION Flight Instructor The flight instructor held an airline transport pilot certificate with an airplane multiengine land rating, and commercial privileges with airplane single-engine land, and glider ratings. He also held a flight instructor certificate with airplane single-engine, multiengine, glider, and instrument ratings. His most recent second-class Federal Aviation Administration (FAA) medical certificate, dated September 2, 2015, contained the restriction, "Must wear corrective lenses." According to the flight instructor's logbooks, he had accumulated 9,898 total hours of flight experience, of which 4,635 hours were in multiengine airplanes, 16 of the multiengine airplane hours were logged in the previous 11 years. He had logged 11.6 total hours in the accident airplane make and model, all within the previous two months, of which 6.7 hours were as a flight instructor. His logbooks indicated that he had never practice stalls in the accident airplane make and model. Pilot Receiving Instruction The pilot receiving instruction held a private pilot certificate with an airplane single-engine land rating. His third-class FAA medical certificate, dated September 2, 2014, contained no restrictions or limitations. According to the pilot's logbook, he had acquired 113.7 total flight hours, of which 110.3 hours were in single-engine airplanes. The remaining 3.4 hours were in the accident airplane make and model. The Galveston County Medical Examiner, Texas City, Texas, conducted an autopsy on the flight instructor. The cause of the pilot's death was listed as blunt force injuries. FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing. Testing was negative for carbon monoxide and ethanol. Metoprolol was detected in urine and subclavian blood. According to FAA's Forensic Toxicology Drug website, metoprolol Is a "beta-adrenergic receptor antagonist, 'beta blocker,' used in the treatment of hypertension and certain arrhythmias." At 1752, Scholes International Airport (KGLS), Galveston, Texas, Automated Surface Observation System, about 11 miles east of the accident site,reported wind from 110° at 11 knots, visibility, 10 miles, scattered clouds at 2,300 ft, temperature, 28° C., dew point, 24° C., and an altimeter setting of 29.79 inches of mercury. Data from the U. S. Naval Observatory showed that sunset occurred at 1902 and the end of evening nautical twilight occurred at 1925. The airplane impacted a tree-lined canal next to a fallow rice field in a slightly wings-level, nose-down attitude. The aircraft wreckage was recovered and transported to Air Salvage of Dallas, Lancaster, Texas, where examinations were conducted. No pre-existing discrepancies or anomalies were noted with the airframe or either engine, and nothing was found that would have precluded the engines from developing power. The bottoms of both propeller spinners were flattened.

## Aircraft

- Registration: [N76S](https://openairdocs.org/deregistered/N76S-2019-09-06), registration cancelled 2019-09-06, S/N TD-605, built 1965 (OpenAirDocs)
- Reported make and model: BEECH D95A
- Registry model: [Beech D95A](https://openairdocs.org/model/beech-d95a) (registry code 1153408) (OpenAirDocs)
- Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: TD-605
- Year built: 1965
- Engines: Lycoming IO-360-B1B 180 horsepower reciprocating; Lycoming IO-360-B1B 180 horsepower reciprocating
- Damage: Destroyed
- Flight: Instructional, Part 91
- Airworthiness certificate: Standard, Normal
- Departed: LVJ, HOUSTON, TX
- Destination: LVJ, HOUSTON, TX
- Equipment: Auto-pilot, Data recorder, Handheld GPS, Stall warning system

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Flight instructor; age 69; injuries: fatal; airline transport, commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: right; restraint: lap only; toxicology performed; flight hours: 9,898 total, 12 in this make and model
- Pilot; age 38; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; seat: left; restraint: 3-point; flight hours: 114 total, 3 in this make and model

## Weather

- Conditions: Visual (VMC), Day
- Wind: 110° at 11 knots
- Visibility: 10 statute miles
- Temperature: 82 °F, dew point 75 °F
- Altimeter: 29.79 inHg
- Observed at: KGLS, 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 20161004016199A](https://openairdocs.org/incident/20161004016199A), Oct 4, 2016: Beech D95A, Hitchcock, TX, Destroyed, 1 fatal. 10/04/2016 The FAA was notified that N76S crashed in a rice field near Hitchcock, TX. The aircraft was located in a small, tree-lined canal adjacent to a rice…

## Docket (14 files)

The files NTSB released with the investigation on October 20, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94140. 13.6 MB in all.

- Witness Statements (item 1, .PDF, 190 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457202&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF
- Witness Video, N76S (item 2, .PDF, 161 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457203&FileExtension=.PDF&FileName=Witness%20Video,%20N76S-Master.PDF
- Maps of Accident Area (item 3, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457204&FileExtension=.PDF&FileName=Maps%20of%20Accident%20Area-Master.PDF
- Weather Reports and Records Pertinent to the Investigation (item 4, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457205&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records%20Pertinent%20to%20the%20Investigation-Master.PDF
- N76S GPS Flight Profile (item 5, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457206&FileExtension=.PDF&FileName=N76S%20GPS%20Flight%20Profile-Master.PDF
- Engine Data Monitor - Specialist's Factual Report (item 6, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457207&FileExtension=.PDF&FileName=Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report-Master.PDF
- Attachment 1 to Engine Data Monitor - Specialist's Factual Report (item 7, .CSV, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457208&FileExtension=.csv&FileName=Attachment%201%20to%20Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report-Master.csv
- IIC's Estimate of the Flight Instructor's Flight Experience (item 8, .PDF, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457209&FileExtension=.PDF&FileName=IIC%27s%20Estimate%20of%20the%20Flight%20Instructor%27s%20Flight%20Experience-Master.PDF
- IIC's Estimate of the Private Pilot's Flight Experience (item 9, .PDF, 207 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457210&FileExtension=.PDF&FileName=IIC%27s%20Estimate%20of%20the%20Private%20Pilot%27s%20Flight%20Experience-Master.PDF
- NTSB Safety Recommendations A-81-49 through -53 (item 10, .PDF, 438 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457211&FileExtension=.PDF&FileName=NTSB%20Safety%20Recommendations%20A-81-49%20through%20-53-Master.PDF
- Toxicological Report (item 11, .PDF, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457212&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF
- Certification of Party Representative to NTSB Investigation (item 12, .PDF, 432 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457213&FileExtension=.PDF&FileName=Certification%20of%20Party%20Representative%20to%20NTSB%20Investigation-Master.PDF
- Release of Aircraft Wreckage, NTSB Form 6120.15 (item 13, .PDF, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458646&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF
- Report Photos (item 14, .PDF, 8 photos, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457214&FileExtension=.PDF&FileName=Report%20Photos-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.

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