# NTSB CEN19FA177: Beech A36, N6150X, Elida, OH, June 20, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 20, 2019, 16:12 local (20:12 UTC) - Place: Elida, OH - Coordinates: 40.846389, -84.158332 - Nearby events: https://openairdocs.org/map.md?lat=40.8464&lon=-84.1583&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report May 19, 2020 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Flight Standards, Continental Aerospace Technologies, Textron Aviation - NTSB case key (mKey): 99677 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19FA177 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99677/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99677 - Page: https://openairdocs.org/ntsb/CEN19FA177 ## Probable cause The noninstrument-rated pilot's decision to continue visual flight rules flight into an area of instrument meteorological conditions, which resulted in a loss of control due to spatial disorientation. Contributing was the pilot not obtaining a weather briefing prior to the flight. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Beech A36, 5 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=1151604), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech A36, 43 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1151604), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech A36, 27 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1151604), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Experience/qualifications: qualification/certification](https://openairdocs.org/ntsb-findings/02031010): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [Beech A36, 3 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md?model=1151604), [All aircraft, 280 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md) - [Planning/preparation: weather planning](https://openairdocs.org/ntsb-findings/02061020): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech A36, 3 cases](https://openairdocs.org/ntsb-findings/02061020/cases.md?model=1151604), [All aircraft, 156 cases](https://openairdocs.org/ntsb-findings/02061020/cases.md) - [Ceiling/visibility/precip: below VFR minima](https://openairdocs.org/ntsb-findings/03035075): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Beech A36, 3 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md?model=1151604), [All aircraft, 184 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md) - [Ceiling/visibility/precip: below VFR minima](https://openairdocs.org/ntsb-findings/03035075): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Beech A36, 3 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md?model=1151604), [All aircraft, 184 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401); cases with it: [Beech A36, 4 cases](https://openairdocs.org/ntsb-events/401/sequence.md?model=1151604), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Enroute: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Beech A36, 31 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1151604), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech A36, 78 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151604), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The noninstrument-rated private pilot and passenger departed on the cross-county flight under visual flight rules (VFR) in visual meteorological conditions and proceeded on course at an altitude of about 9,000 ft mean sea level (msl). As the flight progressed, the weather conditions deteriorated, and about halfway through the flight, the pilot appeared to deviate before resuming flight toward the destination and descended to about 2,000 ft msl over about 30 minutes. Within 20 miles of the accident site, the pilot executed multiple course changes, including two 360° turns. The airplane then entered a right turn from a southeasterly course to a southwesterly course, and about 1 minute before the accident, the airplane re-entered the right turn, which progressed into a right graveyard spiral that continued until impact. Weather observations and satellite imagery indicated that instrument meteorological conditions (IMC) prevailed in the vicinity of where the pilot began making the multiple course changes and at the accident site. It is likely that the pilot encountered rain, and possibly heavy rain, during the final portion of the flight. There was no record of the pilot obtaining a preflight weather briefing from an official source. Examinations of the airframe and engine did not reveal any anomalies consistent with a preimpact failure or malfunction. Toxicology testing of the pilot revealed the presence of carboxy-delta-9-tetrahydrocannabinol (THC), an inactive metabolite of THC. The low-level presence of the inactive THC metabolite suggests that the pilot was not under the influence of THC at the time of the flight, and therefore, it is unlikely that any effects from the pilot's prior use contributed to the accident. The testing also revealed the presence of diphenhydramine; however, it did not provide a blood level. Therefore, whether the pilot might have been impaired from the diphenhydramine at the time of the accident or whether his prior use contributed to the accident could not be determined. The restricted visibility conditions present in the area were conducive to the development of spatial disorientation, and the airplane's maneuvering and spiraling descent are consistent with the known effects of spatial disorientation. It is likely that the pilot experienced spatial disorientation during an encounter with instrument meteorological conditions, which resulted in a loss of control. ## Factual narrative Spatial Disorientation The FAA Civil Aeromedical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a loss of proper bearings or a state of mental confusion as to position, location, or movement relative to the position of the earth. Factors contributing to spatial disorientation include changes in acceleration, flight in instrument meteorological conditions (IMC), frequent transfer between VMC and IMC, and unperceived changes in aircraft attitude. The FAA Airplane Flying Handbook describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part: The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. The FAA Pilot's Handbook of Aeronautical Knowledge provides information concerning spatial disorientation and vestibular illusions. Regarding the "graveyard spiral" illusion, it states: A pilot in a prolonged coordinated, constant-rate turn may experience the illusion of not turning. During recovery to level flight, the pilot will then experience the sensation of turning in the opposite direction causing the disoriented pilot to return the aircraft to its original turn. Because an aircraft tends to lose altitude in turns unless the pilot compensates for the loss of lift, the pilot may notice a loss of altitude. The absence of any sensation of turning created the illusion of being in a level descent. The pilot may pull back on the control sin an attempt to climb or stop the descent. This action tightens the spiral and increase the loss of altitude; this illusion is referred to as a "graveyard spiral." This may lead to a loss of aircraft control. On June 20, 2019, at 1612 eastern daylight time, a Beech A36 airplane, N6150X, was destroyed when it was involved in an accident near Elida, Ohio. The private pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot departed Maquoketa Municipal Airport (OQW), Maquoketa, Iowa, about 1255 and was destined for Toledo Executive Airport (TDZ), Toledo, Ohio. Visual meteorological conditions prevailed near OQW about the time of departure and weather information indicated that the initial portion of the flight was conducted in visual meteorological conditions. However, weather conditions deteriorated as the flight progressed. Automatic Dependent Surveillance – Broadcast (ADS-B) position data indicated that the airplane climbed to an altitude of about9,000 ft mean sea level (msl) and proceeded southeast before turning east and transitioning south of the Chicago, Illinois, metropolitan area while maintaining 9,000 ft msl. The pilot subsequently returned to a southeasterly course until nearing Logansport, Indiana, when he again took up an easterly course and transitioned south of Ft. Wayne, Indiana. During this time, the airplane began a gradual descent over the next 30 minutes eventually leveling at 2,000 ft. msl. The track data depicted multiple course changes, including two 360° turns within 20 miles of the accident site. About 1610:45, the airplane entered a right turn, changing its course from southeasterly to southwesterly over about 30 seconds. About 1611:15, the airplane entered a second right turn, which transitioned into a right descending spiral until the final data point at 1612:14. At that time, the airplane was located about 1/4 mile north-northwest of the accident site at an altitude of 2,110 ft msl, which was about 1,330 ft above ground level (agl). At 1647, a local resident saw the wreckage in an agricultural field and contacted authorities. There were no known witnesses to the accident. An autopsy of the pilot conducted by the Lucas County Coroner's Office, Toledo, Ohio, attributed his death to multiple blunt traumatic injuries sustained in the accident. Toxicology testing was performed by the FAA Forensic Sciences Laboratory. The testing detected 2.2 (ng/mL, ng-g) carboxy-delta-9-tetrahydrocannabinol (THC) in cavity blood and 16.5 (ng/mL, ng/g) in liver tissue; diphenhydramine in muscle and liver tissue; and rosuvastatin in muscle and liver tissue. No ethanol and no carboxyhemoglobin were detected in cavity blood. Carboxy-delta-9-THC is an inactive metabolite of THC. Although THC itself is the primary psychoactive component in marijuana and is considered to be impairing, the inactive metabolite, carboxy-delta-9-THC, is not considered to be impairing. Diphenhydramine is an antihistamine available as an over-the-counter medication commonly used to treat allergy symptoms and as a sleep aid. Due to its sedating effects, it is considered to be impairing. Rosuvastatin is a cholesterol lowering medication available by prescription and is not considered to be impairing. There was no record that the pilot obtained an official preflight weather briefing or that he had requested any weather information during the flight. At 1555, conditions at the Putnam County Airport (OWX), Ottawa, Ohio, about 14 miles north-northeast of the accident location, included scattered clouds at 600 ft agl, broken clouds at 1,700 ft agl, and 5 miles visibility. At 1555, conditions at the Van Wert County Airport (VNW), Van Wert, Ohio, about 20 miles west of the accident site, included broken clouds at 500 ft agl, overcast clouds at 1,000 ft agl, and 2 miles visibility in rain. Satellite imagery depicted cloudy conditions across the region. Overcast clouds prevailed near the accident site, with cloud topsabove 10,000 ft msl and localized build-ups to about 30,000 ft msl. The presence of any intervening cloud layers was not known. Radar imagery depicted light to heavy precipitation across the region. The accident occurred as the airplane approached an area of moderate to heavy perception. An AIRMET warning of instrument conditions was in effect at the time of the accident. Federal Aviation Administration (FAA) records indicated that the pilot did not hold, nor had he ever applied for an instrument rating. His application for the addition of a seaplane rating, dated March 15, 2017, indicated a total instrument flight time of 1.0 hours. The pilot's logbook was not available during the investigation; however, a copy of the pilot's flight review endorsement was provided after the initial factual report was released.. The investigation was not able to determine if the pilot had completed any instrument training after issuance of his private pilot certificate. The pilot did not hold a current medical certificate; however, he had applied for BasicMed. He completed the BasicMed course on May 29, 2017, and his Comprehensive Medical Examination Checklist was completed on May 15, 2017. The pilot was medically eligible to fly as long he had a valid driver's license and was in compliance with 14 Code of Federal Regulations Part 68, Requirements for operating small aircraft without a medical certificate. The accident site was located in an agricultural field. The debris field extended about 117 ft north-northeast of the main wreckage. The airplane came to rest upright on a northwest heading. The engine was separated from the airframe and located in position immediately adjacent to the fuselage. The left wing was partially separated from the fuselage, bent forward 90o, and located resting against the forward fuselage. The right wing and empennage remained attached to the fuselage. The control surfaces remained attached to the airframe. Examination of the airframe and engine did not reveal any anomalies consistent with a preimpact failure or malfunction. A detailed summary of the accident site and the postaccident examinations is available in the public docket. ## Aircraft - Registration: [N6150X](https://openairdocs.org/deregistered/N6150X-2019-11-22), registration cancelled 2019-11-22, S/N E-1961, built 1981 (OpenAirDocs) - Reported make and model: Beech A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-1961 - Year built: 1981 - Airframe hours: 2801.1 - Engines: Continental IO-550-B 300 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Utility - Last inspection: Annual, June 14, 2019 - Departed: OQW, Maquoketa, IA - Destination: TDZ, Toledo, OH - Equipment: ADS-B, Auto-pilot, Electronic multifunction display, Onboard weather, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: fatal; private; airplane ratings: single-engine land, single-engine sea; medical: basicmed; last flight review March 11, 2019; seat: left; restraint: 3-point; toxicology performed; flight hours: 1,640 total ## Weather - Conditions: Instrument (IMC), Day - Wind: 250° at 18 knots, gusting 28 - Visibility: 6 statute miles - Lowest ceiling: 800 ft overcast - Temperature: 66 °F, dew point 64 °F - Altimeter: 29.57 inHg - Observed at: AOH, 10 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 20190620001359A](https://openairdocs.org/incident/20190620001359A), Jun 20, 2019: Beech A36, Elida, OH, Destroyed, 2 fatal. On June 20, 2019, about 1612 eastern daylight time, a Beech A36 airplane, N6150X, was destroyed during a collision with terrain near Elida, Ohio. The pilot and… ## Other investigations on N6150X (1) 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. - [NTSB FTW98LA213](https://openairdocs.org/ntsb/FTW98LA213), May 10, 1998: Beech A-36 (N6150X), Ruidoso, NM, substantial damage. Probable cause: Inadvertent post departure stall. A factor was high gusty winds. ## Docket (17 files) The files NTSB released with the investigation on April 13, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99677. 22.6 MB in all. - Plot of Airplane Position Data (item 1, .PDF, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482277&FileExtension=.PDF&FileName=Plot%20of%20Airplane%20Position%20Data-Master.PDF - ADS-B Data for N6150X (item 2, .CSV, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482278&FileExtension=.csv&FileName=ADS-B%20Data%20for%20N6150X-Master.csv - Wreckage Diagram (Ohio State Patrol) (item 3, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482279&FileExtension=.PDF&FileName=Wreckage%20Diagram%20(Ohio%20State%20Patrol)-Master.PDF - Examination Summary (item 4, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482280&FileExtension=.PDF&FileName=Examination%20Summary-Master.PDF - Report Photos (item 5, .PDF, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482281&FileExtension=.PDF&FileName=Report%20Photos-Master.PDF - Maintenance Records -- Airframe (item 6, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482282&FileExtension=.PDF&FileName=Maintenance%20Records%20--%20Airframe-Master.PDF - Maintenance Records -- Engine (item 7, .PDF, 748 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482283&FileExtension=.PDF&FileName=Maintenance%20Records%20--%20Engine-Master.PDF - Maintenance Records -- Propeller (item 8, .PDF, 207 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482284&FileExtension=.PDF&FileName=Maintenance%20Records%20--%20Propeller-Master.PDF - Weather Documentation (item 9, .PDF, 949 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482285&FileExtension=.PDF&FileName=Weather%20Documentation-Master.PDF - Toxicological Report (item 10, .PDF, 236 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482286&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - FAA Aviation Physiology -- Spatial Disorientation (item 11, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482287&FileExtension=.PDF&FileName=FAA%20Aviation%20Physiology%20--%20Spatial%20Disorientation-Master.PDF - FAA Pilot's Handbook of Aeronautical Knowledge (Excerpt) -- Spatial Disorientation (item 12, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482288&FileExtension=.PDF&FileName=FAA%20Pilot%27s%20Handbook%20of%20Aeronautical%20Knowledge%20(Excerpt)%20--%20Spatial%20Disorientation-Master.PDF - FAA Pilot Safety Brochure -- Spatial Disorientation (item 13, .PDF, 345 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482289&FileExtension=.PDF&FileName=FAA%20Pilot%20Safety%20Brochure%20--%20Spatial%20Disorientation-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 14, .PDF, 547 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482291&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 15, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482290&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Conversation Summary -- Pilot's Son (item 16, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40487269&FileExtension=.PDF&FileName=Conversation%20Summary%20--%20Pilot%27s%20Son-Master.PDF - Flight Review Endorsement (item 17, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40487270&FileExtension=.PDF&FileName=Flight%20Review%20Endorsement-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.