# NTSB ERA11LA048: Bean R E/R B Weld Glasair III, N7SY, Winchester, TN, November 5, 2010 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: November 5, 2010, 09:18 local (14:18 UTC) - Place: Winchester, TN - Coordinates: 35.008888, -86.00389 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.0089&lon=-86.0039&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: 2 fatal - Status: Completed, report August 11, 2011 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 77737 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA11LA048 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/77737/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=77737 - Page: https://openairdocs.org/ntsb/ERA11LA048 ## Probable cause The pilot's inadvertent climb and entry into instrument meteorological conditions during a course reversal, which resulted in spatial disorientation and a loss of control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Bean R E/R B Weld GLASAIR III, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=05614YY), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Ceiling/visibility/precip: low ceiling](https://openairdocs.org/ntsb-findings/03035010): Environmental issues › Conditions/weather/phenomena · Response/compensation; cases with it: [Bean R E/R B Weld GLASAIR III, 1 case](https://openairdocs.org/ntsb-findings/03035010/cases.md?model=05614YY), [All aircraft, 190 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md) - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Bean R E/R B Weld GLASAIR III, 1 case](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=05614YY), [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. - [Maneuvering-low-alt flying: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401); cases with it: [Bean R E/R B Weld GLASAIR III, 1 case](https://openairdocs.org/ntsb-events/401/sequence.md?model=05614YY), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Bean R E/R B Weld GLASAIR III, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05614YY), [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: [Bean R E/R B Weld GLASAIR III, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05614YY), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The accident airplane was one of two airplanes on a multi-leg, cross-country flight. The airplanes were operating at 2,500 feet mean sea level (msl), at 200 knots, with an overcast cloud layer about 300 feet above them. The pilots encountered deteriorating weather conditions about 40 miles prior to a planned fuel stop. The lead pilot turned to its left, and according to data extracted from the GPS receiver on board, the accident pilot initiated a climb, and then a course reversal to the right. During the turn to the right, the airplane climbed to nearly 3,800 feet, slowed to 144 knots, descended to 2,000 feet and accelerated to 255 knots, climbed back to 4,000 feet and slowed to 39 knots at the second-to-last data plot which was in the vicinity of the crash site. Two witnesses said they heard the airplane, and one witness observed it before ground contact. Examination of the crash site and the wreckage revealed damage to the trees and the airplane that were consistent with a near vertical descent and engine power at impact. The pilot of the lead airplane stated that he checked the weather prior to their departure, and that the weather conditions were clear all the way to their destination. However, AIRMETs for icing conditions from the surface to 10,000 feet, as well as for mountain obscuration due to clouds and precipitation were current along the planned route of flight in the area surrounding the accident site. The airplane's rapid, near-vertical descent, turning ground track and the meteorological conditions are consistent with the pilot's loss of control of the airplane due to spatial disorientation. ## Factual narrative HISTORY OF FLIGHT On November 5, 2010, about 0918 central daylight time, an experimental amateur-built, Bean Glassair III, N7SY, was destroyed during collision with wooded, mountainous terrain following an uncontrolled descent while maneuvering near Winchester, Tennessee. The certificated private pilot and the pilot-rated passenger/builder were fatally injured. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the personal flight which was conducted under the provisions of 14 Code of Federal Regulations Part 91. The flight of two airplanes, lead by an airline transport-rated pilot (ATP) in a Tews Swearingen SX300, N3RT, departed Port Orange, Florida (7FL6), with a planned fuel stop in Shelbyville, Tennessee (SYI). During telephone interviews with a Federal Aviation Administration (FAA) inspector, two witnesses said they heard the airplane, and one witness observed it before ground contact. Both witnesses described the engine noise as increasing and decreasing "for some time," and one likened it to a crop duster as it made low-level passes. The witness who observed the airplane said it descended vertically and sounded as though it was at "full power" before it disappeared into the trees and the sounds of impact were heard. The ATP in the second aircraft was interviewed by the FAA inspector, and a Safety Board investigator, and he provided a similar account to each. According to the ATP, the flight departed 7FL6 on an IFR plan with an ultimate destination of Iowa City, Iowa. He stated he checked the weather and it was "clear all the way to Iowa." While en route to their first fuel stop, the ATP said they changed altitudes and obtained both visual flight rules (VFR) and IFR clearances to take advantage of better routing, winds, and to fly underneath layers of class B airspace. Ultimately, the flight descended to 2,500 feet mean sea level (msl) due to weather. While operating VFR about 40 miles southeast of SYI, the ATP noticed a ridgeline about 10 miles ahead of their position was obscured by clouds. He advised a course reversal to seek a landing site with available fuel. The accident airplane pilot concurred with the decision, and the lead aircraft initiated a left, 180-degree turn. The accident airplane pilot, flying in a right echelon position, announced and then initiated a right, 180-degree turn. Seconds later, the ATP heard the passenger in the accident airplane state over the radio, "Don't do that." Several seconds later he again heard the passenger state, "Don't follow that." He said there was a pause of about ten seconds when he then heard the voice of the pilot say, "Oh God, no." The ATP stated that at the point where the flight reversed course, they were cruising about 2,500 feet mean sea level, at 200 knots. An overcast cloud layer was "a few hundred feet" above his airplane, and the terrain was 800 to 1,000 feet below. A Garmin 496 hand-held GPS was recovered from the wreckageand forwarded to the Safety Board Vehicle Recorders Laboratory in Washington, D.C. A preliminary examination of data revealed that between 0805 and 0851, the accident airplane maintained an approximate ground track of 330 degrees, about 4,200 feet, and 200 knots groundspeed when it then initiated a descent. By 0905, the airplane had descended to 2,250 feet just prior to initiating a climb, a slight left turn, and then a course reversal to the right. During the turn to the right, the airplane climbed to nearly 3,800 feet, and slowed to 144 knots, then descended to 2,000 feet and accelerated to 255 knots, then climbed back to 4,000 feet and slowed to 39 knots at the second-to-last data plot which was in the vicinity of the crash site. About 0908, between the second-to-last and last data plot, a sharp, descending left turn back to the northwest was depicted. PERSONNEL INFORMATION According FAA records, the pilot held a private pilot certificate with ratings for airplane single engine and instrument airplane. The pilot's most recent FAA third-class medical certificate was issued on February 18, 2010, with the limitation "must wear corrective lenses." She reported 800 total hours of flight experience on that date. The pilot's logbook was recovered, and a cursory examination of the logbook revealed 951.9 total hours of flight experience logged. She logged 921 total hours of single-engine airplane time, and 74 hours of actual instrument time. The passenger/builder held a private pilot certificate with a rating for airplane single engine. He also held a certificate for repairman experimental aircraft builder. His most recent FAA third-class medical certificate was issued June 8, 2010, and he reported 60 hours of total flight experience on that date. The passenger/builder's logbook was not recovered. AIRCRAFT INFORMATION According to FAA records, an airworthiness certificate was issued for the airplane in 2003. The airplane's logbooks were not recovered, therefore the airplane's total aircraft hours and maintenance history could not be determined. METEOROLOGICAL INFORMATION At 0918, the weather reported at Winchester Municipal Airport (BGF), 979 feet elevation, 11 nautical miles to the northwest, included a scattered cloud layer at 900 feet, an overcast layer at 1,600 feet, and 3 miles visibility. The winds were from 340 degrees at 7 knots, the temperature was 4 degrees C, the dew point was 2 degrees C and the altimeter setting was 29.93 inches of mercury. AIRMETs for icing from the surface to 10,000 feet, as well as for mountain obscuration due to clouds and precipitation were current along the planned route of flight in the area surrounding the accident site. The witnesses stated that the weather conditions around the crash site on the morning of the accident included fog, mist, and rain. WRECKAGE AND IMPACT INFORMATION The wreckage was examined at the accident site by the FAA inspector on November 5, 2010. There was a strong odor of fuel, and allmajor components were accounted for at the scene. The damage to the trees was limited to two trees directly above the wreckage, and angularly cut wood was discovered at the site. According to the inspector, the wreckage was "compacted," and the damage was consistent with a vertical descent. Examination of photographs taken at the crash site confirmed the inspector's observations, and displayed damage consistent with a vertical descent. MEDICAL AND PTHOLOGICAL INFORMATION Postmortem examination of the pilot and pilot-rated passenger was performed by the Office of the Medical Examiner, Nashville, Tennessee. The cause of death for both occupants was reported as multiple blunt force injuries. Postmortem toxicology testing on specimens obtained from the pilot and pilot rated passenger was performed by the FAA's Civil Aeromedical Institute, Oklahoma City, Oklahoma. The tests were negative for ethanol and drugs for both occupants. ADDITIONAL INFORMATION FAA-H-8083-25, "Pilot's Handbook of Aeronautical Knowledge," states, "Spatial disorientation specifically refers to the lack of orientation with regard to the position, attitude, or movement of the airplane in space." According to the AC, among the steps "which should assist materially in preventing spatial disorientation" were: (1) Before you fly with less than 3 miles visibility obtain training and maintain proficiency in aircraft control by reference to instruments. (2) Check weather forecasts before departure, en route, and at destination. Be alert for weather deterioration. (3) Do not attempt visual flight rule flight when there is a possibility of getting trapped in deteriorating weather. (4) Rely on instrument indications unless the natural horizon or surface reference is clearly visible. FAA AC 61-134, "General Aviation Controlled Flight into Terrain Awareness," states, "According to National Transportation Safety Board (NTSB) and FAA data, one of the leading causes of GA accidents is continued VFR flight into IMC... The importance of complete weather information, understanding the significance of the weather information, and being able to correlate the pilot's skills and training, aircraft capabilities, and operating environment with an accurate forecast cannot be emphasized enough....VFR pilots in reduced visual conditions may develop spatial disorientation and lose control." According to AC60-4A, accidents that involved spatial disorientation "resulted in fatalities over 90 percent of the time." ## Aircraft - Registration: [N7SY](https://openairdocs.org/deregistered/N7SY-2014-11-18), registration cancelled 2014-11-18, S/N 3063, built 2003 (OpenAirDocs) - Reported make and model: BEAN R E/R B WELD INC GLASAIR III - Registry model: [Bean R E/R B Weld GLASAIR III](https://openairdocs.org/model/bean-r-e-r-b-weld-glasair-iii) (registry code 05614YY) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 3063 - Engines: LYCOMING IO-540 SER 300 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: R B Weld Inc - Registered owner: R B Weld Inc - Airworthiness certificate: Special, Experimental (Special) - Departed: 7FL6, Port Orange, FL - Destination: SYI, Shelbyville, TN - Flight plan: VFR/IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 952 total - Co-pilot; age 68; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; toxicology performed; flight hours: 60 total ## Weather - Conditions: Visual (VMC), Day - Wind: 340° at 7 knots - Visibility: 3 statute miles - Lowest ceiling: 1,600 ft overcast - Temperature: 39 °F, dew point 36 °F - Altimeter: 29.93 inHg - Observed at: KBGF, 10 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 20101105049339A](https://openairdocs.org/incident/20101105049339A), Nov 5, 2010: Bean R E/R GLASAIR III, Winchester, TN, Destroyed, 2 fatal. Aircraft was part of a flight of two aircraft. During course reversal due to weather, aircraft control was lost and the aircraft impacted terrain vertically.… ## Docket (9 files) The files NTSB released with the investigation on June 14, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=77737. 4.5 MB in all. - FAA Inspector Statement (item 1, .PDF, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344851&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Redacted.PDF - Witness Interview Summaries (item 2, .PDF, 176 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344881&FileExtension=.PDF&FileName=Witness%20Interview%20Summaries-Redacted.PDF - Weather Reports and Records (item 3, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344853&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Global Positioning System Device - Specialist's Factual Report (item 4, .PDF, 322 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342238&FileExtension=.PDF&FileName=Global%20Positioning%20System%20Device%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Global Positioning System Device - Attachment 1 (item 5, .CSV, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342237&FileExtension=.csv&FileName=Global%20Positioning%20System%20Device%20-%20Attachment%201-Master.csv - Pilot Toxicology Report (item 6, .PDF, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344865&FileExtension=.PDF&FileName=Pilot%20Toxicology%20Report-Master.PDF - Copilot Toxicology Report (item 7, .PDF, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344864&FileExtension=.PDF&FileName=Copilot%20Toxicology%20Report-Master.PDF - Accident Photographs (4) (item 8, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344874&FileExtension=.PDF&FileName=Accident%20Photographs%20(4)-Master.PDF - Accident Location Map (item 9, .PDF, 647 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344852&FileExtension=.PDF&FileName=Accident%20Location%20Map-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.