# NTSB CEN19FA323: Beech V35, N5438U, London, OH, September 18, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: September 18, 2019, 07:31 local (11:31 UTC) - Place: London, OH - Coordinates: 39.93222, -83.470558 - Nearby events: https://openairdocs.org/map.md?lat=39.9322&lon=-83.4706&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - 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 - NTSB case key (mKey): 100285 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19FA323 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100285/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100285 - Page: https://openairdocs.org/ntsb/CEN19FA323 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Light condition: glare](https://openairdocs.org/ntsb-findings/03036030): Environmental issues › Conditions/weather/phenomena · Contributed to outcome (probable cause); cases with it: [Beech V35, 1 case](https://openairdocs.org/ntsb-findings/03036030/cases.md?model=1151538), [All aircraft, 109 cases](https://openairdocs.org/ntsb-findings/03036030/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 V35, 2 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=1151538), [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 V35, 8 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1151538), [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. - [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Beech V35, 6 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1151538), [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 V35, 12 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151538), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N5438U-2023-04-25), registration cancelled 2023-04-25, S/N D-8509, built 1967 (OpenAirDocs) - Reported make and model: Beech V35 - Registry model: [Beech V35](https://openairdocs.org/model/beech-v35) (registry code 1151538) (OpenAirDocs) - Registry engine: [Continental GTSIO-520-C](https://openairdocs.org/engine/continental-gtsio-520-c) (registry code 17035, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-8509 - Year built: 1967 - Airframe hours: 2427 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 79; injuries: fatal; 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 ## 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 20190918013309A](https://openairdocs.org/incident/20190918013309A), Sep 18, 2019: Beech V35, London, OH, Destroyed, 1 fatal. Private pilot departed his personal airfield near piqua Ohio at approximately 1100Z enroute for kuyf (Madison County Airport, London Ohio). Video evidence… ## Docket (12 files) The files NTSB released with the investigation on June 1, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100285. 14.0 MB in all. - Witness statements (item 1, PDF, 2 pages, 821 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9540042&FileExtension=pdf&FileName=%5B3%5DWitness_%20Statements_Redacted-Rel_Redacted-Rel.pdf - Memorandum (item 2, PDF, 1 page, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9342141&FileExtension=pdf&FileName=%5B4%5DMemorandum-Rel.pdf - Csv data (item 3, PDF, 25 pages, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9154894&FileExtension=pdf&FileName=%5B4%5DCSV%20Data-Rel.pdf - ADS-B and radar data (item 4, MP4, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9341903&FileExtension=mp4&FileName=%5B6%5DADS-B%20and%20Radar%20Data-Rel.mp4 - ADS-B final approach on google earth (item 5, PDF, 1 page, 336 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9341912&FileExtension=pdf&FileName=%5B8%5DADS-B%20Final%20Approach%20on%20Google%20Earth-Rel.pdf - Wreckage diagram (item 6, PDF, 1 page, 23 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9450790&FileExtension=pdf&FileName=%5B9%5DWreckage%20Diagram-Rel.pdf - Conversation with FAA inspectpr (item 7, PDF, 1 page, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9156744&FileExtension=pdf&FileName=%5B8%5DConversation%20with%20FAA%20Inspector%20Paul%20Gillenwater-Rel.pdf - Beech V35 stall speeds (item 8, PDF, 1 page, 144 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8535236&FileExtension=pdf&FileName=%5B10%5DBeech%20V35%20Stall%20Speeds-Rel.pdf - Toxicology reports (item 9, PDF, 3 pages, 267 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9360482&FileExtension=pdf&FileName=%5B11a%5DToxicology%20Reports_Redacted-Rel.pdf - Certification of party representatives to NTSB investigation (item 10, PDF, 2 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8956783&FileExtension=pdf&FileName=%5B10a%5DCertification%20of%20Party%20Representatives%20to%20NTSB%20Investigation_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 11, PDF, 1 page, 705 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12295954&FileExtension=pdf&FileName=%5B13a%5DNTSB%20Form%206120.15,%20Release%20of%20Aircraft%20Wreckage_Redacted-Rel_Redacted-Rel.pdf - Report photos (item 12, PDF, 12 pages, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8954814&FileExtension=pdf&FileName=%5B12%5DReport%20Photos-Rel.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.