# NTSB ERA11FA321: Beech V35, N29MW, Ellijay, GA, May 30, 2011 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: May 30, 2011 - Place: Ellijay, GA - Coordinates: 34.741664, -84.351669 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.7417&lon=-84.3517&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Fatal - Injuries: 4 fatal - 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 - NTSB case key (mKey): 79275 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA11FA321 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/79275/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=79275 - Page: https://openairdocs.org/ntsb/ERA11FA321 ## Probable cause The pilot’s failure to maintain adequate clearance from terrain while maneuvering in a mountainous area. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech V35B, 3 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=1151548), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Terrain: mountainous/hilly terrain](https://openairdocs.org/ntsb-findings/03021010): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Beech V35B, 1 case](https://openairdocs.org/ntsb-findings/03021010/cases.md?model=1151548), [All aircraft, 329 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech V35B, 4 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=1151548), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Beech V35B, 5 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=1151548), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## 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](https://openairdocs.org/deregistered/N29MW-2013-08-29), registration cancelled 2013-08-29, S/N D-10086, built 1977 (OpenAirDocs) - Reported make and model: BEECH V35 (B) - Registry model: [Beech V35B](https://openairdocs.org/model/beech-v35b) (registry code 1151548) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-10086 - Airframe hours: 3044 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: fatal; 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 ## 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 20110530018169A](https://openairdocs.org/incident/20110530018169A), May 30, 2011: Beech V35B, Ellijay, GA, Destroyed, 4 fatal. Aircraft departed 49A on a local VFR flight on Monday, may 30, 2011 at 1033L. When the aircraft did not return, a search was initated. The aircraft was located… ## Docket (20 files) The files NTSB released with the investigation on August 12, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=79275. 8.6 MB in all. - Witness Statements (item 1, .PDF, 176 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40373278&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Witness Statement: Airport Representative. (item 2, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381906&FileExtension=.PDF&FileName=Witness%20Statement%3A%20Airport%20Representative.-Redacted.PDF - Miscellaneous: Record of Conversation. (item 3, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381919&FileExtension=.PDF&FileName=Miscellaneous%3A%20Record%20of%20Conversation.-Redacted.PDF - Miscellaneous: A Google Geographical Terrain Depiction of the Accident Location. (item 4, .PDF, 377 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381928&FileExtension=.PDF&FileName=Miscellaneous%3A%20A%20Google%20Geographical%20Terrain%20Depiction%20of%20the%20Accident%20Location.-Master.PDF - Miscellaneous: 47A Weather Information (item 5, .PDF, 146 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381916&FileExtension=.PDF&FileName=Miscellaneous%3A%2047A%20Weather%20Information-Master.PDF - Miscellaneous: Airplane Performance Reference. (item 6, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382052&FileExtension=.PDF&FileName=Miscellaneous%3A%20Airplane%20Performance%20Reference.-Redacted.PDF - Excerpts From the Airplane's Maintenance Records. (item 7, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383068&FileExtension=.PDF&FileName=Excerpts%20From%20the%20Airplane%27s%20Maintenance%20Records.-Redacted.PDF - Altimeter History (item 8, .PDF, 319 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383048&FileExtension=.PDF&FileName=Altimeter%20History-Redacted.PDF - Reports from Parties to the Investigation: McCauley Propeller (item 9, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40373281&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%3A%20McCauley%20Propeller-Redacted.PDF - Reports from Parties to the Investigation: Excerpts From Continental Motors, Inc. (item 10, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383049&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%3A%20Excerpts%20From%20Continental%20Motors,%20Inc.-Redacted.PDF - Pilot's Toxicological Report (item 11, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381907&FileExtension=.PDF&FileName=Pilot%27s%20Toxicological%20Report-Redacted.PDF - Fueling Related Items (item 12, .PDF, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383050&FileExtension=.PDF&FileName=Fueling%20Related%20Items-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 13, .PDF, 278 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383051&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Retention / Release of Wreckage Form (item 14, .PDF, 275 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40373277&FileExtension=.PDF&FileName=Retention%20%2F%20Release%20of%20Wreckage%20Form-Redacted.PDF - Photo 1)View of the Trees Over the Wreckage Area. (item 15, .PDF, 508 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381728&FileExtension=.PDF&FileName=Photo%201)View%20of%20the%20Trees%20Over%20the%20Wreckage%20Area.-Master.PDF - Photo 2) View of the Burnt Wreckage Among the Trees at Ground Level. View Aft of Airplane Looking Forward (item 16, .PDF, 503 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381730&FileExtension=.PDF&FileName=Photo%202)%20View%20of%20the%20Burnt%20Wreckage%20Among%20the%20Trees%20at%20Ground%20Level.%20View%20Aft%20of%20Airplane%20Looking%20Forward-Master.PDF - Photo 3) View of the Burnt Wreckage Among the Forest's ground. View Front of the Airplane Looking Aft. (item 17, .PDF, 533 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381732&FileExtension=.PDF&FileName=Photo%203)%20View%20of%20the%20Burnt%20Wreckage%20Among%20the%20Forest%27s%20ground.%20View%20Front%20of%20the%20Airplane%20Looking%20Aft.-Master.PDF - Photo 4) Close up View of the Burnt Engine Nacelle section and Engine Wreckage. (item 18, .PDF, 496 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381733&FileExtension=.PDF&FileName=Photo%204)%20Close%20up%20View%20of%20the%20Burnt%20Engine%20Nacelle%20section%20and%20Engine%20Wreckage.-Master.PDF - Photo 5) Close up View of the Propeller and Spinner Attached to the Engine. (item 19, .PDF, 479 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381734&FileExtension=.PDF&FileName=Photo%205)%20Close%20up%20View%20of%20the%20Propeller%20and%20Spinner%20Attached%20to%20the%20Engine.-Master.PDF - Photo 6)View of Recovered Tree Branches Cut by Propeller Strikes. (item 20, .PDF, 513 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381738&FileExtension=.PDF&FileName=Photo%206)View%20of%20Recovered%20Tree%20Branches%20Cut%20by%20Propeller%20Strikes.-Master.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.