CEN19FA323

NTSB accident investigation · Beech V35 · London, OH · September 18, 2019

Accident · FatalClass 3 · FieldFinal report
Date
September 18, 2019, 07:31 local (11:31 UTC)
Place
London, OH
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N5438UBeech V35
Defining event
Maneuvering-low-alt flying: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Continental Aerospace Technologies, FAA Flight Standards District Office, Textron Aviation
FAA report
20190918013309A
Case key
100285

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

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Probable cause

The pilot’s exceedance of the airplane’s critical angle of attack while maneuvering toward the final leg of the traffic pattern and facing the rising sun, which resulted in a subsequent aerodynamic stall at too low an altitude to recover.

Findings · 3

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.

Light condition: glareEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeBeech V35: 1 caseAll aircraft: 109 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech V35: 2 casesAll aircraft: 1,269 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotBeech V35: 8 casesAll aircraft: 9,295 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 pilot was conducting a cross-country, personal flight. He had departed from his private airstrip and was on final approach for landing at his destination airport. One witness stated that it appeared that “the pilot overshot the runway and was banking back towards the east to make another approach.” The airplane banked too steeply and then “dove” toward the ground. He added that the pilot might have been “blinded” by the rising sun “as he banked and looked back east.” Another witness reported seeing the airplane “flying parallel to the highway” with it wings “perpendicular to the ground.” After the airplane flew over the highway, it banked “hard to the left and was too low to recover.” He then noticed a “flash” as if the right aileron had reflected the sunlight and the pilot was trying to bank right to level off but had insufficient airspeed “to correct.” The eastbound witness also had a dashboard camera, which captured the airplane's landing approach. The video showed the airplane fly east, parallel to the highway, then fly over the highway to the south, bank to the east, and then descend out of sight. The sun was about 2° above the horizon at an azimuth of about 89° at the time of the accident, and given the airplane’s position, it would have been shining directly into the pilot's eyes. The airplane impacted terrain about 520 ft west of the approach end of the landing runway and 50 ft north of the extended runway centerline. Postimpact fire consumed most of the cabin, instrument panel, fuselage, and right wing. Postaccident examination of the airplane revealed that the main landing gear were down and that the flaps were set to 20° down. There were no mechanical anomalies with the airplane that would have precluded normal operations. Based on the available evidence, it is likely that the pilot exceeded the airplane’s critical angle of attack while maneuvering toward the final leg of the traffic pattern and facing the rising sun after overshooting the runway, which resulted in an aerodynamic stall at too low of an altitude to recover.

Factual narrative

Maintenance records were not located during the course of the investigation. On September 18, 2019, at 0731 eastern daylight time, a Beech V35 airplane, N5438U, was destroyed when it was involved in an accident at Madison County Airport (UYF), London, Ohio. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to a Federal Aviation Administration (FAA) inspector, the pilot was flying to UYF to attend the Ohio State University Farm Science Review. He departed from his personal airstrip, Apple Airstrip (0OH7), Piqua, Ohio, about 0715. He did not file a flight plan. Two people witnessed the accident. One witness was westbound on a highway in front of UYF. He stated it appeared that "the pilot overshot the runway and was banking back towards the east to make another approach.” The airplane then banked too steeply and “dove” toward the ground. He added that the pilot "may have been blinded [by the sun] as he banked and looked back east." The other witness was eastbound on the highway. He reported that he noticed an airplane "flying parallel to the highway” to his left (north) with its wings “perpendicular to the ground.” After the airplane flew over the highway, it “banked hard to the left and was too low to recover.” He then noticed a “flash” as if the right aileron had reflected the sunlight and the pilot was trying to bank right to level off but had insufficient airspeed “to correct." The eastbound witness had a dashboard camera, which captured the airplane's landing approach. The video showed the airplane fly east, parallel to the highway, then fly over the highway to the south, bank to the east, and then descend out of sight. The bright, rising sun directly faced the camera. An autopsy was performed by the Montgomery County Coroner's Office. The cause of death was "multiple trauma." The FAA's Bioaeronautical Sciences Laboratory conducted toxicology tests on specimens from the pilot. The tests detected no evidence of ethanol or carboxyhemoglobin. Metoprolol and amlodipine were detected in cavity blood and liver, and benazepril was detected in cavity blood. Metoprolol, amlodipine, and benazepril are prescription medications that are commonly used to control high blood pressure. None of these medications are generally considered impairing. According to the NOAA Solar Calculator, the sun was about 2° above the horizon at an azimuth of about 89° at the time of the accident. The airplane impacted terrain in a left-wing, nose-low attitude on a magnetic heading of 045° about 520 ft west of the approach end of runway 9. It came to rest about 118 ft northeast of the initial impact point, which was about 50 ft north of the extended runway centerline. Postimpact fire consumed most of the cabin, instrument panel, fuselage, and right wing. The control yoke and rudder pedal assemblies were partially consumed by fire. One arm of the right-wing aileron bellcrank was fractured, butthe control cable remained attached. The right flap actuator was consumed by fire, but the left flap actuator was estimated at 20° down. The fuel selector valve was found positioned to the right fuel tank. The main landing gear (MLG) push-pull tubes were bent, and the MLG was down and locked. Flight control continuity was established. The engine could not be manually rotated due to its position at the accident site. The top spark plug leads from each magneto sparked when the magnetos were rotated. Both propeller blades were separated from the propeller hub, which remained attached to the engine. One propeller blade’s leading edge exhibited tip curling and impact damage, and the other propeller blade’s leading edge exhibited signatures consistent with the engine producing power at impact. There were no mechanical anomalies with the airframe or engine that would have precluded normal operations.

Aircraft

Registration
N5438U
Reported as
Beech V35
Category
Airplane
Serial number
D-8509
Built
1967
Airframe hours
2,427
Engine
Continental TSIO-520-D, 285 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 5, 2019
Departed
0OH7 · Piqua, OH
Destination
UYF · London, OH
Airport
UYF · Madison County, runway 09, 4,001 × 75 ft, asphalt
Equipment
Stall warning system

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
79
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Seat
Left
Restraint
Lap only
Toxicology
Performed
Flight hours
2,010 total · 2,010 in this make and model · 15 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
10° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
55 °F, dew point 54 °F
Altimeter
30.14 inHg
Observed at
UYF

Docket · 12

The files NTSB released with the investigation on June 1, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 14.0 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.