# NTSB CEN23LA028: Beech E-90, N809DM, Slidell, LA, November 7, 2022 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: November 6, 2022, 21:45 local (Nov 7, 2022, 03:45 UTC) - Place: Slidell, LA · wooded terrain - Coordinates: 30.354207, -89.818646 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.3542&lon=-89.8186&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR missed approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA - FSDO, Textron Aviation - NTSB case key (mKey): 106256 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23LA028 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106256/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=106256 - Page: https://openairdocs.org/ntsb/CEN23LA028 ## Probable cause The pilot’s failure to maintain airplane control during an attempted go-around in low visibility conditions. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Attention/monitoring](https://openairdocs.org/ntsb-findings/02021500): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Beech E-90, 1 case](https://openairdocs.org/ntsb-findings/02021500/cases.md?model=1152914), [All aircraft, 18 cases](https://openairdocs.org/ntsb-findings/02021500/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 E-90, 3 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1152914), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech E-90, 1 case](https://openairdocs.org/ntsb-findings/01062022/cases.md?model=1152914), [All aircraft, 526 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md) - [Performance/control parameters: yaw control](https://openairdocs.org/ntsb-findings/01062024): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech E-90, 1 case](https://openairdocs.org/ntsb-findings/01062024/cases.md?model=1152914), [All aircraft, 149 cases](https://openairdocs.org/ntsb-findings/01062024/cases.md) - [Ceiling/visibility/precip: low visibility](https://openairdocs.org/ntsb-findings/03035015): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Beech E-90, 1 case](https://openairdocs.org/ntsb-findings/03035015/cases.md?model=1152914), [All aircraft, 175 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Beech E-90, 1 case](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=1152914), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR missed 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) - [Approach-IFR missed approach: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech E-90, 8 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1152914), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot flew a visual approach to his home airport but did a go-around due to ground fog. After receiving an instrument flight rules clearance, he flew an RNAV/GPS approach that he also discontinued due to ground fog. After executing a missed approach, the pilot flew another RNAV/GPS approach. The pilot reported that during this last approach he lost visual references and initiated a go-around, during which the airplane impacted trees about 800 ft to the right of the runway. The main wreckage came to rest upright and was consumed by a post-impact fire. The postaccident examination revealed no preimpact anomalies that would have precluded normal operation. The pilot reported that he observed the right engine was slower to accelerate than the left engine during the attempted go-around, and that he was distracted looking at the engine indications. He reported that he did not notice if the airplane yaw to the right and, before he could correct for the altitude loss, the airplane descended into and struck the trees. ## Factual narrative On November 6, 2022, about 2145 central standard time, a Beech E-90, N809DM, was destroyed when it was involved in an accident at Slidell Airport (ASD), Slidell, Louisiana. The pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 positioning flight. According to air traffic control information, the airplane departed John C. Tune Airport (JWN), Nashville, Tennessee, and climbed to a cruise altitude of 22,000 ft. The airplane descended to ASD, the pilot’s home airport, and a visual approach was flown that the pilot discontinued due to ground fog. The pilot received an instrument flight rules clearance and flew the RNAV (GPS) RWY 36 approach that he also discontinued due to ground fog. After executing a missed approach, the pilot flew another RNAV (GPS) RWY 36 approach, during which the airplane impacted terrain about 800 ft right of the departure end of Runway 36. The pilot egressed the airplane without assistance. The airplane initially impacted trees with the right wing (see Figure 1). The main wreckage came to rest upright and was consumed by a post-impact fire. The postaccident examination of the airplane revealed no preimpact anomalies that would have precluded normal operation. Figure 1. Wreckage Diagram, Courtesy of Textron Aviation ASD was equipped with an Automated Surface Observation System (ASOS). At 2153, the ADS ASOS observation was wind calm, visibility 5 statute miles in mist, ceiling overcast at 400 ft above ground level (agl), temperature 19°C and dew point 18°C. At 2135, the closest weather reporting station about 12 miles northeast of ASD reported wind calm, visibility 1/4 mile in fog, ceiling overcast at 200 ft agl, temperature 20°C, and dew point temperature 20°C. Several other weather stations in the vicinity reported low ceilings and visibilities, with fog forming over the area. There were no pilot weather reports (PIREPs) within 60 miles of ASD in the national database from 1700 through 2400. The pilot reported that, during the last attempted approach, he initiated a go-around after losing sight of visual references due to ground fog. He observed the right engine was slower to accelerate than the left engine during the go-around, and that he was distracted looking at the engine indications. He reported that he did not notice if the airplane yawed to the right, and before he could correct for the altitude loss, the airplane descended into the trees. Other pilots who flew the airplane reported the right engine’s acceleration was sometimes slower than the left engine. The director of maintenance had performed a timed engine run and found the right engine acceleration time was slower than the left engine, but within the normal range of the maintenance manual. ## Aircraft - Registration: [N809DM](https://openairdocs.org/aircraft/N809DM), registered now, S/N LW-334, built 1980 (OpenAirDocs) - Reported make and model: BEECH E-90 - Registry model: [Beech E-90](https://openairdocs.org/model/beech-e-90) (registry code 1152914) (OpenAirDocs) - Registry engine: [U/A Canada PT6A-27-28](https://openairdocs.org/engine/u-a-canada-pt6a-27-28) (registry code 61504, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: LW-334 - Year built: 1980 - Airframe hours: 7111 - Engines: Pratt & Whitney PT6A-28 750 horsepower turbo prop; Pratt & Whitney PT6A-28 750 horsepower turbo prop - Damage: Destroyed - Fire: On-Ground - Flight: Positioning, Part 91 - Operator: Air Reldan, Inc. - Registered owner: Air Reldan, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, September 15, 2022 - Departed: JWN, Nashville, TN - Destination: ASD, Slidell, LA - Flight plan: IFR - Airport: ASD, Slidell Airport, runway 36, 5,002 × 100 ft, asphalt - Equipment: Onboard weather, Stall warning system, ADS-B, Angle of attack indicator, Auto-pilot, Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: serious; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review September 7, 2022; seat: left; restraint: 3-point; flight hours: 4,800 total, 325 in this make and model ## Weather - Conditions: Instrument (IMC), Night - Wind: calm - Visibility: 5 statute miles - Temperature: 66 °F, dew point 64 °F - Altimeter: 30.11 inHg - Observed at: KASD, 1 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 20221106013409A](https://openairdocs.org/incident/20221106013409A), Nov 6, 2022: Beech E-90, Slidell, LA, Destroyed. On O6 nov 22, E-90 [privacy data omitted] was being flown from kjwn nashville to kasd Slidell on a repositioning flight. The aircraft was not on an IFR flight… ## Docket (8 files) The files NTSB released with the investigation on April 10, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=106256. 23.9 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16375008&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - FAA air traffic control accident report - excerpt (item 2, PDF, 7 pages, 966 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16375610&FileExtension=pdf&FileName=FAA%20Air%20Traffic%20Control%20Accident%20Report%20-%20Excerpt-Rel.pdf - Correspondence with FAA inspector (item 3, PDF, 2 pages, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16416129&FileExtension=pdf&FileName=Correspondence%20with%20FAA%20Inspector-Rel.pdf - Meteorology factual (item 4, PDF, 22 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15964921&FileExtension=pdf&FileName=CEN23LA028%20-%20Slidell,%20LA%20WX%20Factual-Rel.pdf - ADS-B raw data (item 5, CSV, 17.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16375728&FileExtension=csv&FileName=20221107_AB03A3_500082644_ADSB-Rel.csv - ADS-B data - google earth graphic (item 6, KMZ, 513 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16376263&FileExtension=kmz&FileName=20221107_AB03A3_500082644_ADSB-Rel.kmz - Aircraft examination report (item 7, PDF, 5 pages, 721 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16376092&FileExtension=pdf&FileName=Aircraft%20Examination%20Summary-Rel.pdf - Statement of party representatives to NTSB investigation (item 8, PDF, 1 page, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16374696&FileExtension=pdf&FileName=Party%20Form%20-%20Textron_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. --- 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.