ERA11FA321

NTSB accident investigation · Beech V35 · Ellijay, GA · May 30, 2011

Accident · FatalField investigationFinal report
Date
May 30, 2011
Place
Ellijay, GA
Injuries
4 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N29MWBeech V35
Defining event
Maneuvering: Controlled flight into terr/obj (CFIT)
Weather
Visual (VMC) · Day
Status
Completed · report October 29, 2013
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
McCauley Propller Systems, Hawker Beechcraft Corporation, Continental Motors Incorporated, FAA/FSDO
FAA report
20110530018169A
Case key
79275

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 failure to maintain adequate clearance from terrain while maneuvering in a mountainous area.

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.

Action: incorrect action performancePersonnel issues › Action/decision · PilotBeech V35B: 3 casesAll aircraft: 1,386 casesProbable cause
Terrain: mountainous/hilly terrainEnvironmental issues › Physical environment · Contributed to outcomeBeech V35B: 1 caseAll aircraft: 329 cases
Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech V35B: 4 casesAll aircraft: 1,310 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 morning of the accident, the pilot departed with three passengers for a local sightseeing flight. The airplane was last seen flying in an easterly direction. Two days after the flight was reported overdue, the wreckage was located on a mountain side at an estimated elevation of 2,990 feet mean sea level. Damage to the surrounding foliage and wreckage debris at the accident site indicated that the airplane was in a right-wing-low attitude when it made initial contact with a 50-foot-tall tree. The propeller cut several tree branches before the airplane impacted the ground where it came to rest flat. The airplane was consumed by postimpact fire; the tail empennage section and the engine with propeller were discernible. Although the airframe sustained thermal damage, the postaccident airframe examination did not reveal any evidence of preimpact mechanical malfunction or failure that would have precluded normal operation. A postaccident engine run also did not indicate any malfunction or failure that would have prevented normal operation and production of rated power. The postaccident propeller examination revealed that it was in a low-pitch position with power applied at the time of impact. Maintenance documentation for the airplane noted that its altimeter was not reading correctly; no corrective action was reflected in the airplane’s maintenance logbooks. However, the flight was conducted in visual meteorological conditions, and the weather on the day of the accident was such that the pilot’s ability to “see and avoid” was not hindered. According to the pilot’s Federal Aviation Administration medical certification file, he had received a statement of demonstrated ability for limited vision in his left eye and was taking medication for high cholesterol. No other medications were reported at the time of his last aviation medical examination. However, postmortem toxicological testing identified bupropion and quetiapine in the pilot’s tissues. Bupropion, marketed under the trade names Zyban and Wellbutrin, is an atypical antidepressant used to treat depression and to help smokers quit using cigarettes. Quietapine, marketed under the trade name Seroquel, is an antipsychotic used to treat schizophrenia and bipolar disease. The extent to which these medications may have affected the pilot’s performance was not determined.

Factual narrative

HISTORY OF FLIGHT On May 30, 2011, at an unknown time, a Beech V35B, N29MW, collided with terrain on Rich Mountain, in the Chattahoochee National Forest, Ellijay, Georgia. The airplane sustained substantial damage. The pilot and three passengers received fatal injuries. The airplane had departed from the Gilmer County Airport (49A), Ellijay, Georgia, about 1033 that day. Visual meteorological conditions prevailed and no flight plan had been filed for the personal flight conducted under the provisions of Title 14 Code of Federal Regulations Part 91. According to a representative from the fix base operator, the out of state pilot arrived to 49A on May 27, 2011 to attend a social event. On May 29, he offered a sightseeing flight which flew over mountainous terrain and over the Carter and Blue Ridge Lakes area. The sightseeing flight returned back to 49A within an hour from its departure. After that flight the airplane was fueled with 32 gallons of aviation fuel and placed in a hangar. On the morning of May 30, the airplane was pulled out of the hanger for another sightseeing flight with different passengers. The airplane departed from runway 21 and was last seen flying in an easterly direction. Friends and family members notified the authorities when the flight did not return. A search & rescue operation was initiated. The wreckage was located on June 1, 2011. PERSONNEL INFORMATION The pilot, age 68, held a private pilot certificate with ratings for airplane single engine and multi-engine land, and instrument airplane. He was issued a third-class medical certificate on March 16, 2011, with limitation of must wear corrective lenses. He documented 2,800 total hours at that time. The pilot’s flight logbook was not recovered and presumed to be among the wreckage. AIRCRAFT INFORMATION The Beech V35B was built in 1977, serial number D-10086. On November 23, 1977 the airplane was issued a standard airworthiness certificate and registered in the utility category. The airplane was equipped with a Teledyne Continental Motors IO-520-BA, 285 horsepower rated engine, with a three bladed McCauley, constant speed, propeller. The airplane incorporated a retractable tricycle landing gear and had a “V” tail design for the rudder and elevator flight control surface system. The airplane was maintained in accordance with the manufacturers recommended maintenance program. A review of the airplanes maintenance records revealed the airplane had an annual inspection on the airframe, propeller, and engine on January 10 2011, at which time the airplane had accumulated a total of 3,044 hours, the engine was new with 0 hour, and the propeller had accumulated 895 hours since overhauled. The airplane’s engine had maintenance performed on April 28, 2011. METEOROLOGICAL INFORMATION The closest official weather observation was at the Gilmer County Airport (49A), Ellijay, Georgia, 8 miles southwest of the accident site. The 49A May 30, 2011, 1025 automated weather observing system(AWOS) was wind from 020 degrees at 3 knots; visibility, 10 statute miles; sky clear; temperature 29 degrees Celsius (C); dew point 13 degrees C; altimeter 30.29 inches of mercury; density altitude 3100 feet. WRECKAGE and IMPACT INFORMATION The geographical terrain of the accident site was an estimated 270 degrees radius, approximately 1.5 miles in width by 1 mile in length, of rising terrain. The highest terrain being on the northeast section, at an estimated 4,000 feet mean sea level (msl) and lowest terrain located at the south-southwest section, at an estimated 2, 000 feet msl; approximately one mile in width at its widest point. The wreckage was located on the northeast section of the area at an estimated elevation of 2,990 feet msl, about 8 miles from 49A. The wreckage area had numerous trees of average of 70 feet in height with heavy top and ground foliage. Damage to the surrounding foliage at the accident site indicated that the airplane was right wing low and on a 90-degrees heading when it made its initial contact with a tree, at an estimated height of 50 feet above ground level (agl). The airplane’s right wing fuel tip tank was located underneath that area. The next impact was with trees, about 80 feet from the initial impact point, at an estimated height of 30 feet agl, scrape marks on the tree’s barks were observed, which ran down the trees to where the airplane came to rest, indicative of low forward energy. The airplane came to rest on a 090 degrees heading. Remnants of the airplane were observed flat on the estimated 25-degrees sloped terrain. The airplane’s left wing fuel tip tank was located several feet forward of the main wreckage with thermal damage. The cabin entrance door with impact and thermal damaged was located several feet away from the right side of the main wreckage. The left aileron, with impact and thermal damage, was located forward of the main wreckage. The airplane’s wings, cockpit, cabin, minus 3 feet of the empennage section were consumed by thermal damage. Landing gear location among the main wreckage and damage was consistent with them in the retracted position. The remaining empennage section was observed crushed and with a twist deformity toward the right (down slope). The remnant of the emergency locator transmitter (ELT) was located in the thermal damaged fuselage area. The left stabilizer was observed separated and folded over the right stabilizer, which came to rest on the ground. All flight control surfaces, and /or remnants of them, were present at the accident site. Flight control continuity was established up to the control column section, which was consumed by thermal damage. Majority of the fire was concentrated within the wreckage with an estimated 100 feet in diameter of the surrounding ground foliage consumed by fire. The tree top foliage along the energy path and in front of the wreckage was observed with fuel burns. The firewall and engine, with cowling attached, were intact with impact andthermal damage. Both came to rest on their right side. Engine controls continuity was established from the engine to the thermal damaged engine control levers section. The three bladed propeller remained attached to the engine crankshaft. All three of the propeller blades were loose and rotated freely at the hub. One blade was observed bowed forward. The second blade was observed twisted and bent aft. The third blade was observed bent aft from the hub base. The propeller’s spinner remained intact with minimal damage. A post recovery wreckage examination was performed by the airframe and engine manufacturer with National Transportation Safety Board (NTSB) oversight. The examination revealed remnants of the engine fuel mixture, propeller, and throttle control cables were consistent with full forward position. Remnants of the engine cowl flap control cable were consistent with the open position. Fuel tank selector position could not be determined due to the thermal damage. The left and right fuel caps were engaged in the adapter ring. The debris free pitot tube was separated and with thermal damage. The left and right flap actuator extension could not be measured due to thermal damage. Molten aluminum captured the flap roller in a position consistent with the left and right flap in the retracted (up) position. The elevator trim actuator measured approximately 0.6 inches, corresponding to an approximate 13 degrees tab down (surface up) position. The engine exhibited varying degrees of impact and thermal related damage. The thermal damage was concentrated on the aft portion of the engine in addition to the left side cylinders. The upper ignition leads and all fuel and oil hoses on the back side of the engine were with thermal damage. The engine remained attached to the mounting tunnel assembly and various cables, hoses, and wires. The front left engine mount fractured, the other three were intact. Engine accessories remained attached. The fuel pump was removed and rotated freely by hand. The fuel pump drive coupling was intact and undamaged. The fuel pump inlet fitting separated flush with the vapor separator housing. The throttle body and metering assembly exhibited impact related damage with the metering shaft visually bent in an upward orientation. The top spark plugs were removed and the engine was rotated by hand using the propeller flange. Thumb compressions and valve train continuity were established on each of the six cylinders. Accessory gear continuity was established during the rotation of the propeller flange. The engine rotated freely by hand with no binding or stiffness noted. The oil filler cap/dipstick was removed and a small amount of residual oil was observed on the bottom of the dipstick. MEDICAL AND PATHOLOGICAL INFORMATION The Georgia Bureau of Investigation, Division of Forensic Sciences in Decatur, Georgia, conducted a postmortem examination of the pilot and passengers. The cause of death for all was blunt force trauma andthermal injuries. The FAA Civil Aeromedical Institute (CAMI) conducted toxicology testing on specimens from the pilot. The tests were negative for carbon monoxide, cyanide, and ethanol. The drug test was positive for Bupropion and Quetiapine. TEST AND RESEARCH With the NTSB oversight the engine was run at the manufacturer’s facility. The engine run did not indicate any abnormalities that would have prevented normal operation and production of rated power. A propeller teardown examination was performed at the manufacturer’s facility with FAA oversight. The examination revealed that all propeller damage were consistent with impact forces. Internal impact marks were consistent with blades in the low pitch position at time of impact. Blade bending, twisting, and overall propeller damage were those associated with power apply at impact. A research by the Federal Aviation Administration revealed that on May 7, 2010 the airplane’s altimeter had a discrepancy that prevented the instrument from working correctly. The airplane’s maintenance records did not reflect any corrective action to the altimeter. The drugs detected in the pilot’s toxicology testing are used to treat psychiatric conditions. The uses of those drugs are disqualifying for a FAA medical certificate and were not reported on the pilot’s most recent medical application form. The condition(s) and the medications can degrade mental performance and may result in impaired judgment.

Aircraft

Registration
N29MW
Reported as
Beech V35 (B)
Category
Airplane
Serial number
D-10086
Airframe hours
3,044
Engine
Continental IO520, 285 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Utility
Last inspection
Annual · January 10, 2011
Departed
49A · Ellijay, GA
Destination
49A · Ellijay, GA

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
68
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
2,800 total

Weather

Conditions
Visual (VMC) · Day
Wind
20° at 3 knots
Visibility
10 statute miles
Temperature
84 °F, dew point 55 °F
Altimeter
30.29 inHg
Observed at
49A, 8 nm away

Docket · 20

The files NTSB released with the investigation on August 12, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.6 MB in all.

Witness StatementsItem 1 · .PDF · 176 KBWitness Statement: Airport Representative.Item 2 · .PDF · 39 KBMiscellaneous: Record of Conversation.Item 3 · .PDF · 81 KBMiscellaneous: A Google Geographical Terrain Depiction of the Accident Location.Item 4 · .PDF · 377 KBMiscellaneous: 47A Weather InformationItem 5 · .PDF · 146 KBMiscellaneous: Airplane Performance Reference.Item 6 · .PDF · 114 KBExcerpts From the Airplane's Maintenance Records.Item 7 · .PDF · 2.1 MBAltimeter HistoryItem 8 · .PDF · 319 KBReports from Parties to the Investigation: McCauley PropellerItem 9 · .PDF · 86 KBReports from Parties to the Investigation: Excerpts From Continental Motors, Inc.Item 10 · .PDF · 1.3 MBPilot's Toxicological ReportItem 11 · .PDF · 79 KBFueling Related ItemsItem 12 · .PDF · 178 KBStatement of Party Representatives to NTSB InvestigationItem 13 · .PDF · 278 KBRetention / Release of Wreckage FormItem 14 · .PDF · 275 KBPhoto 1)View of the Trees Over the Wreckage Area.Item 15 · .PDF · 508 KBPhoto 2) View of the Burnt Wreckage Among the Trees at Ground Level. View Aft of Airplane Looking ForwardItem 16 · .PDF · 503 KBPhoto 3) View of the Burnt Wreckage Among the Forest's ground. View Front of the Airplane Looking Aft.Item 17 · .PDF · 533 KBPhoto 4) Close up View of the Burnt Engine Nacelle section and Engine Wreckage.Item 18 · .PDF · 496 KBPhoto 5) Close up View of the Propeller and Spinner Attached to the Engine.Item 19 · .PDF · 479 KBPhoto 6)View of Recovered Tree Branches Cut by Propeller Strikes.Item 20 · .PDF · 513 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.