# NTSB CEN23FA190: Beech E-90, N522MJ, Winslow, AR, May 17, 2023

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 3 · Field · Final report
- Date: May 17, 2023, 12:37 local (17:37 UTC)
- Place: Winslow, AR
- Coordinates: 35.8424, -94.1482
- Nearby events: https://openairdocs.org/map.md?lat=35.8424&lon=-94.1482&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Defining event: [Approach-IFR initial approach: 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: Textron, FAA LIT FSDO, Hartzell, Transportation Safety Board of Canada
- NTSB case key (mKey): 174548
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23FA190
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/174548/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=174548
- Page: https://openairdocs.org/ntsb/CEN23FA190

## Probable cause

The pilot’s poor preflight decision to depart into known instrument meteorological conditions (IMC) without a functional autopilot system, which resulted in spatial disorientation and his failure to maintain aircraft control while flying in IMC during the instrument approach. Contributing to the accident was the pilot’s self-imposed pressure to conduct the flight.

## Findings

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

- [Auto flight system: autopilot system](https://openairdocs.org/ntsb-findings/01022210): Aircraft › Aircraft systems · Inoperative; cases with it: [Beech E-90, 1 case](https://openairdocs.org/ntsb-findings/01022210/cases.md?model=1152914), [All aircraft, 28 cases](https://openairdocs.org/ntsb-findings/01022210/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 E-90, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=1152914), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/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 E-90, 2 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1152914), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Personality/attitude: motivation/respond to pressure](https://openairdocs.org/ntsb-findings/02021025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Beech E-90, 1 case](https://openairdocs.org/ntsb-findings/02021025/cases.md?model=1152914), [All aircraft, 53 cases](https://openairdocs.org/ntsb-findings/02021025/cases.md)
- [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Beech E-90, 1 case](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=1152914), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md)

## Sequence of events

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

- [Enroute-descent: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Beech E-90, 8 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1152914), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Approach-IFR initial approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Beech E-90, 8 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1152914), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)

## Analysis

The airplane was being flown to another airport for maintenance work on the autopilot system. Before the flight, the pilot and an avionics technician discussed a roll issue with the airplane’s autopilot and the pilot was advised not to use the autopilot until the issue was resolved. The avionics technician further advised the pilot to wait for good weather to make the flight, but the pilot reportedly had a function back home that he wanted to attend later, on the day of the accident. Recorded flight track data indicated that most of the flight was uneventful until the airplane began its descent toward the intended destination. During the descent, the airplane encountered overcast clouds that continued to the end of the flight. The pilot was subsequently cleared for an instrument approach to the destination airport. While maneuvering on the approach, the airplane descended below its assigned altitude and the controller issued a low-altitude alert to the pilot. The airplane briefly climbed before it entered a descending right turn that continued to the end of the recorded data. Calculations based on recorded flight data revealed the airplane was descending over 15,000 feet per minute shortly before impact. The airplane impacted the ground near the final recorded flight track data point, in a near vertical attitude, and was fragmented. Examination of the airplane, engines, and systems did not reveal any preimpact anomalies that would have precluded normal flight. Based on the available information, the pilot likely was not using the autopilot due to the known issue with the system and, as a result, was hand flying the airplane during the instrument approach. The pilot likely was accustomed to flying the airplane with the automation that the autopilot provided rather than by hand in single-pilot instrument meteorological conditions (IMC). Based on the recorded flight path, it is likely that the pilot became spatially disoriented and lost control of the airplane while intercepting the final approach course for the instrument approach. In addition, the pilot allowed his self-imposed pressure to influence his decision to complete the flight in less-than-ideal weather conditions without a functional autopilot. Although ethanol was detected in liver and muscle tissue, it is likely that some, or all, of the detected ethanol was from postmortem production. Thus, it is unlikely that ethanol contributed to the accident. Tadalafil, salicylic acid, famotidine, atenolol, and irbesartan were detected in liver and muscle tissue, but it is unlikely that these substances contributed to the accident.

## Factual narrative

On May 17, 2023, about 1237 central daylight time, a Beech E-90 airplane, N522MJ, was destroyed when it was involved in an accident near Winslow, Arkansas. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Before the flight, the pilot contacted an avionics repair facility at Drake Field Airport (FYV), Fayetteville, Arkansas, to discuss autopilot issues that he was having with the airplane. He told the avionics technician that when engaged in heading hold mode the autopilot would roll the airplane into a steep left bank. The technician asked the pilot to perform ground checks of the autopilot system, but there were no discrepancies noted. He then asked the pilot to perform a maintenance flight in visual meteorological conditions to test the autopilot system. The pilot told the technician that during the test flight, the airplane still entered a left roll, and that he disengaged the autopilot once a 40° bank was reached. The technician advised the pilot that he would need to bring the airplane in for service and to not utilize the autopilot during the flight. The pilot planned to fly the airplane to FYV and leave it at the avionics facility for maintenance and return home via a commercial flight. On the morning of the accident flight, the pilot called the avionics technician and told him that he may have to delay his departure due to inclement weather at the departure airport. The avionics technician stressed that he told the pilot that there was no urgency on their part and that the pilot should wait for good weather conditions to fly the airplane to FYV. The avionics technician said that the pilot had a function that he wanted to attend back home on the evening of the accident flight. According to recorded ADS-B data, and air traffic control communications, the flight originated from University-Oxford Airport (UOX), Oxford, Mississippi, about 1127, and proceeded on a direct course toward FYV. The airplane climbed to 16,000 ft mean sea level (msl) and remained there until 1221 when a descent was initiated, which continued to 8,000 ft msl. About 1227, the pilot contacted Razorback Approach Control and reported being at 8,000 ft msl. The controller acknowledged and instructed the pilot to fly direct to WAYTUG for the localizer directional aid (LDA) runway 34 approach to FYV and to descend and maintain 5,000 ft msl. WAYTUG was the intermediate/initial approach fix (IF/IAF) for the LDA runway 34 approach to FYV and this approach had been in use at FYV. The airplane started descending but the pilot communicated that he could not locate WAYTUG on his approach chart. After several communications, the controller determined that the pilot was reviewing the RNAV runway 34 approach to FYV. Once clarified, the controller instructed the pilot to cross VIXMU, the IF/IAF, at 4,500 ft msl, and cleared him for the RNAV runway 34 approach to FYV. The airplane then made a turn to the left. Atthis time, the airplane was about 6,100 ft msl. The airplane continued descending and flew toward VIXMU. The airplane then turned to the right before reaching VIXMU and then turned slightly to the left placing it on a 45° intercept for the approach segment between VIXMU and OPVIE, which was the final approach fix (FAF). During this time, the airplane descended to about 3,525 ft msl. The controller advised the pilot that he had received a low altitude alert and instructed the pilot to check altitude. The pilot acknowledged and the airplane climbed back up to 3,950 ft msl. After the airplane climbed to 3,950 ft msl, it entered a right turn, presumably to intercept the inbound approach course, but the airplane continued in the right turn and subsequently entered a steep descent as depicted in figures 1 and 2. The final ADS-B data point, about 0.1 miles from the accident site, was at 1236:26 with a recorded altitude of 2,900 ft msl. The calculated descent rate between the final two data points was more than 15,000 feet per minute. Figure 1. The final portion of the accident flight shown in red with the FYV RNAV 34 approach fixes and approach segments depicted in yellow. Figure 2. A 3-dimensional view of the final portion of the accident flight. The accident location and the approach fix (VIMXU) are depicted. The Arkansas State Medical Examiner performed the pilot’s autopsy. According to the autopsy report, the pilot’s cause of death was multiple traumatic injuries and the manner of death accident. The FAA Forensic Sciences Laboratory performed toxicology testing of postmortem tissue specimens from the pilot. Ethanol was detected in liver tissue at 0.028 g/hg and in muscle tissue at 0.035 g/hg. Tadalafil, salicylic acid, famotidine, atenolol, and irbesartan were detected in liver and muscle tissue. Ethanol is a type of alcohol. It is the intoxicating alcohol in beer, wine, and liquor, and, if consumed, can impair judgment, psychomotor performance, cognition, and vigilance. Alcohol consumption is not the only possible source of ethanol in postmortem specimens. Ethanol can sometimes be produced by microbes in a person’s body after death. Postmortem ethanol production is made more likely by extensive traumatic injury. Tadalafil is a prescription medication commonly used to treat erectile dysfunction, symptoms of an enlarged prostate, or to treat pulmonary hypertension. Occasional use of tadalafil for erectile dysfunction is acceptable for pilots if there are no side effects and a 24-hour waiting period is observed from the last dose before flying. Daily use of tadalafil for an enlarged prostate is also acceptable for pilots if there are no side effects with use, and a week waiting period has passed after initiation of therapy. All the remaining detected medications were acceptable for use by pilots and none were impairing or would have adversely affected performance. The most recent weather report at FYV included an overcast ceiling at 1,800 ft abovethe ground (3,037 ft msl). Based on meteorological information gathered during the investigation, for the cruise portion of the flight at 16,000 ft msl the airplane was above the clouds. The data indicated that the airplane began encountering few clouds about 9,000 ft msl during its descent, and reached the overcast layer about 8,300 ft msl. Meteorological and ADS-B data indicated that the airplane would have remained in the clouds until the steep descending right turn at the end of the flight. The pilot’s flight logbook was not available during the investigation. The pilot reported having 4,836 hours total flight experience as of his most recent 3rd class medical examination on November 7, 2022. A pilot experience form for insurance purposes indicated the pilot had 4,802 total flight hours and 653 hours in multiengine airplanes as of November 9, 2021. Other documents obtained during the investigation indicated that the pilot received a proficiency evaluation in the airplane that was completed on May 20, 2021, and a proficiency evaluation for BE-300 airplanes on June 10, 2022. The airplane impacted wooded terrain, descending through an opening in the tree canopy. The damage to the surrounding trees, the impact signatures and the airplane damage was consistent with a near vertical descent and impact. Both engines and propellers were embedded in the terrain, and the entire airplane was fragmented. All major airframe and flight control surfaces were identified in the immediate vicinity of the impact location. Subsequent examination of the airplane after its removal from the accident site was limited due to the extent of the damage; however, all major airframe components were identified as were portions of all flight control surfaces. All breaks in control system components displayed signatures consistent with overload failure due to impact. Engine and propeller examination revealed signatures consistent with power production at the time of impact.

## Aircraft

- Registration: [N522MJ](https://openairdocs.org/aircraft/N522MJ), registered now, S/N LW-80 (OpenAirDocs)
- Reported make and model: BEECH E-90
- Registry model: [Beech E-90](https://openairdocs.org/model/beech-e-90) (registry code 1152914) (OpenAirDocs)
- Category: Airplane
- Serial number: LW-80
- Year built: 1973
- Airframe hours: 4925
- Engines: Pratt & Whitney PT6A-34 680 horsepower turbo prop; Pratt & Whitney PT6A-34 680 horsepower turbo prop
- Damage: Destroyed
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: AAIP, June 2, 2022
- Departed: UOX, Oxford, MS
- Destination: FYV, Fayetteville, AR
- Flight plan: IFR
- Airport: FYV, Drake Field, runway 34, 6,005 × 100 ft, asphalt
- Equipment: Auto-pilot, ADS-B, Stall warning system

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 76; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review June 10, 2022; seat: left; restraint: 3-point; toxicology performed; flight hours: 4,836 total

## Weather

- Conditions: Instrument (IMC), Day
- Wind: calm
- Visibility: 10 statute miles
- Lowest ceiling: 1,800 ft overcast
- Temperature: 68 °F, dew point 59 °F
- Altimeter: 29.97 inHg
- Observed at: KFYV, 10 nm away
- METAR: METAR KFYV 171735Z AUTO 00000KT 10SM OVC018 20/15 A2997

## 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 20230517008279A](https://openairdocs.org/incident/20230517008279A), May 17, 2023: Beech E-90, Winslow, AR, Destroyed, 1 fatal. On may 17, 2023, about 1127 central daylight time, a Beech E-90 airplane, being operated as a title 14 code of federal regulations (CFR) part 91 personal…

## Docket (18 files)

The files NTSB released with the investigation on July 8, 2025, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=174548. 22.8 MB in all.

- Transcript of ATC communications (item 1, PDF, 2 pages, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18683424&FileExtension=pdf&FileName=ATC%20Transcript-Rel.pdf
- Instrument approach procedure - RNAV (GPS) rwy 34 at fyv (item 2, PDF, 1 page, 270 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18676872&FileExtension=pdf&FileName=00728R34-Rel.pdf
- ADS-B data (xlsx file) (item 3, XLSX, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18677416&FileExtension=xlsx&FileName=20230517_A69178_515828170_ADSB-Rel.xlsx
- ADS-B data (kmz file) (item 4, KMZ, 253 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18676942&FileExtension=kmz&FileName=20230517_A69178_515828170-Rel.kmz
- Plots of ADS-B data (item 5, PDF, 3 pages, 274 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18705293&FileExtension=pdf&FileName=ADS-B%20Plots-Rel.pdf
- Record of conversation with avionics technician (item 6, PDF, 2 pages, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18677139&FileExtension=pdf&FileName=ROC%20with%20avionics%20mechanic-Rel.pdf
- Aircraft examination (item 7, PDF, 5 pages, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18705283&FileExtension=pdf&FileName=Aircraft%20Examination-Rel.pdf
- Maintenance records (phase 1 & 2 inspections) (item 8, PDF, 2 pages, 240 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18677337&FileExtension=pdf&FileName=N522MJ%20Phase%201%20%202%20Inspection_Redacted-Rel.pdf
- Maintenance records (phase 3 & 4 inspections) (item 9, PDF, 2 pages, 240 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18677074&FileExtension=pdf&FileName=N522MJ%20Phase%203%20%204%20Inspection_Redacted-Rel.pdf
- Maintenance records (status sheet) (item 10, PDF, 5 pages, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18704434&FileExtension=pdf&FileName=N522MJ%20Status%20Sheet%20%202022-Rel.pdf
- Pilot documentation (item 11, PDF, 5 pages, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18677454&FileExtension=pdf&FileName=Pilot%20Documentation%20-%20John%20Morgan_Redacted-Rel.pdf
- Medical factual memorandum of record (item 12, PDF, 4 pages, 150 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18650414&FileExtension=pdf&FileName=CEN23FA190_Winslow%20Arkansas%20Medical%20Factual%20Memorandum%20of%20Record-Rel.pdf
- Toxicological report (item 13, PDF, 1 page, 147 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18695581&FileExtension=pdf&FileName=Tox_Redacted-Rel.pdf
- Meteorology - factual report (item 14, PDF, 24 pages, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18705502&FileExtension=pdf&FileName=CEN23FA190%20-%20Winslow,%20AR%20WX%20Factual-Rel.pdf
- Release of aircraft wreckage, NTSB form 6120.15 (item 15, PDF, 1 page, 516 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18676083&FileExtension=pdf&FileName=NTSB%20Wrecakge%20Release%20-%20Complete_Redacted-Rel.pdf
- Photos (item 16, PDF, 12 pages, 7.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18705395&FileExtension=pdf&FileName=Photos-Rel.pdf
- Statement of party representatives to NTSB investigation (hartzell) (item 17, PDF, 1 page, 214 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18705354&FileExtension=pdf&FileName=CEN23FA190%20Hartzell%20Party%20Form-Signed_Redacted-Rel.pdf
- Statement of party representatives to NTSB investigation (Textron) (item 18, PDF, 1 page, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18745445&FileExtension=pdf&FileName=NTSB%20Party%20Certification%20Acknowledgement%20Form%20(Textron)_Redacted-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.

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