# NTSB CEN19FA189: Beechcraft 58, N4614S, Hiawatha, KS, June 28, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 28, 2019, 17:15 local (22:15 UTC) - Place: Hiawatha, KS - Coordinates: 39.887779, -95.517219 - Nearby events: https://openairdocs.org/map.md?lat=39.8878&lon=-95.5172&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report August 25, 2020 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Textron Aviation, Continental Aerospace Technologies, FAA FSDO - NTSB case key (mKey): 99727 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19FA189 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99727/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99727 - Page: https://openairdocs.org/ntsb/CEN19FA189 ## Probable cause The pilot's loss of control for undetermined reasons. ## 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) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech 58, 4 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=1152740), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/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 58, 15 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1152740), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Beech 58, 14 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1152740), [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 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) - [Post-impact: Fire/smoke (post-impact)](https://openairdocs.org/ntsb-events/170); cases with it: [Beech 58, 3 cases](https://openairdocs.org/ntsb-events/170/sequence.md?model=1152740), [All aircraft, 354 cases](https://openairdocs.org/ntsb-events/170/sequence.md) ## Analysis The pilot was on a cross-country flight in a twin-engine airplane. A witness, located at the destination airport, reported that the accident airplane approached the airport from the south and then headed northeast, as if to enter the airport traffic pattern. He added that the airplane appeared to climb and then started a left turn. After starting the turn, the airplane flipped inverted, the nose dropped, and the airplane disappeared from view behind terrain. Examination of the wreckage site, located about 1 mile northeast of the airport, revealed that the airplane had impacted terrain on its bottom fuselage, and came to rest upright. A post-crash fire consumed a majority of the cabin and the inboard sections of the wings. The wreckage was confined to one area and all major components were accounted for on site. Though the examination was limited by thermal and impact damage, no pre-impact abnormalities were observed during the airframe or engines examinations that would have precluded normal operations. A review of the pilot's autopsy and medical history did not identify any evidence of an incapacitating event. The airplane's roll to an inverted attitude is consistent with an inflight loss of control event. The ground scars and damage to the airplane are consistent with a probable attempted recovery from the loss of control; however, the reason for the loss of control could not be determined based on the available information. ## Factual narrative On June 28, 2019, about 1715 central daylight time, a Beechcraft BE-58 airplane, N4614S, impacted terrain during an approach to the Hiawatha Municipal Airport (K87), Hiawatha, Kansas. The pilot was fatally injured, and the airplane was destroyed. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 cross-country personal flight. The pilot was not in contact with air traffic control during the cross-country flight from Augusta Municipal Airport (3AU), Augusta, Kansas. Review of radar information revealed that the airplane proceeded in a northeast direction from the origin airport toward K87the destination; however, the flight track stopped about 3/4-mile northeast of K87 and the final minutes of the flight were not captured. A witness reported that the airplane approached the airport from the south and then proceeded north-northeast as if to enter the traffic pattern. He added that the airplane appeared to climb and then started a left turn. Just after starting the turn, the airplane flipped inverted, the nose dropped, and the airplane descended from view behind terrain. The witness saw smoke and called 911. The Frontier Forensics Midwest Morgue of Kansas City, Kansas, under the authority of the Brown County Coroner's Office, conducted an autopsy on the pilot. The cause of death was due to blunt traumatic injuries and severe burns. The Federal Aviation Administration's (FAA) Forensic Sciences Laboratory, Oklahoma City, Oklahoma, conducted toxicological testing. The specimens were not tested for cyanide. The tests were negative for ethanol and tested drugs. The pilot last medical certificate was issued on March 09, 2017, with no limitations. The pilot's second-class medical certificate expired on March 31, 2019, but he had completed the BasicMed flight medical. The pilot's BasicMed course date was April 16, 2019, and the Comprehensive Medical Examination Checklist (CMEC) was completed on April 12, 2019. The airplane wreckage was located in a corn field about 1-mile northeast of K87. The airplane impacted terrain on its bottom fuselage and came to rest upright on a 171° heading. A post-crash fire consumed a majority of the cabin and the inboard section of the wings. The wreckage was confined to one area, and all major components were accounted for on-site. Figure 1: Wreckage Flight control continuity was limited through the center section of the fuselage due to fire damage, however, the connection at each of the respective flight control surfaces was confirmed. The cockpit/instrument panel was impact and fire damaged. The landing gear handle appeared to be in the down/landing gear extended position. A review of the landing gear actuator position corroborated the landing gear was in the down position. The right flap actuator was partially extended, which corresponded to a flap's 15° extended position. The left and right engines remained attached to their respective airframe locations, and both engines had impact and firedamage. The right 3-bladed propeller separated from the engine crankshaft flange and was located underneath the airplane. The left 3-bladed propeller remained attached to the engine; neither propeller was in the feathered position Both engines were rotated by hand, and thumb compression and suction were noted on each cylinder. The valve covers were removed and continuity through the valve train to the accessory section was observed. The left engine's left magneto produced spark at each terminal; the engine's right magneto was fire damaged and would not rotate. The right engine's left magneto produced spark at each terminal. The right magneto was fire damaged and did not produce spark at the terminals; however, spark was observed at the magneto points. Each engine's fuel system, including the fuel manifold, fuel pump, fuel nozzles, and fuel screen were field examined, and no pre-impact abnormalities were noted. The top set of sparkplugs were removed from both engines, and normal combustion and wear signatures were observed. Though the examination was limited by thermal and impact damage, no pre-impact abnormalities were observed during the airframe or engines examinations that would have precluded normal operations. ## Aircraft - Registration: [N4614S](https://openairdocs.org/deregistered/N4614S-2021-08-20), registration cancelled 2021-08-20, S/N TH-684, built 1975 (OpenAirDocs) - Reported make and model: Beechcraft 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-684 - Year built: 1975 - Airframe hours: 3591.8 - Engines: Continental IO-520 285 horsepower reciprocating; Continental IO-520 285 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 10, 2018 - Departed: 3AU, Augusta, KS - Destination: K87, Hiawatha, KS - Airport: K87, Hiawatha Municipal Airport, runway 17, 3,400 × 100 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 67; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: basicmed; seat: left; toxicology performed; flight hours: 1,498.4 total, 318.7 in this make and model, 1,351.6 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 200° at 13 knots, gusting 18 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 93 °F, dew point 75 °F - Altimeter: 29.95 inHg - Observed at: KFNB, 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 20190628008309A](https://openairdocs.org/incident/20190628008309A), Jun 28, 2019: Beech 58, Hiawatha, KS, Destroyed, 1 fatal. During approach to the Hiawatha airport (K87), the airplane impacted terrain approximately 0.5NM north of the airport. A witness stated that the airplane… ## Docket (10 files) The files NTSB released with the investigation on August 7, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99727. 16.8 MB in all. - Witness (item 1, .PDF, 750 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40485970&FileExtension=.PDF&FileName=Witness-Master.PDF - Site Location (item 2, .PDF, 8.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40485971&FileExtension=.PDF&FileName=Site%20Location-Master.PDF - Fllight Track (item 3, .PDF, 509 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40485972&FileExtension=.PDF&FileName=Fllight%20Track-Master.PDF - Flight track log (item 4, .PDF, 149 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40485973&FileExtension=.PDF&FileName=Flight%20track%20log-Master.PDF - Pilot Flight Time (item 5, .PDF, 389 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40485974&FileExtension=.PDF&FileName=Pilot%20Flight%20Time-Master.PDF - Aircraft Records (Excerpts) (item 6, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40485975&FileExtension=.PDF&FileName=Aircraft%20Records%20(Excerpts)-Master.PDF - Photos (item 7, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40485976&FileExtension=.PDF&FileName=Photos-Master.PDF - Toxicological Report (item 8, .PDF, 303 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40485977&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 9, .PDF, 662 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40485978&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 946 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40485979&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.