# NTSB ERA12LA535: Beech 95-A55, N71BM, Millville, NJ, August 29, 2012 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: August 29, 2012, 14:45 local (18:45 UTC) - Place: Millville, NJ - Coordinates: 39.370277, -75.07611 - Nearby events: https://openairdocs.org/map.md?lat=39.3703&lon=-75.0761&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-flare/touchdown: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report November 6, 2013 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: CMI, FAA/FSDO - NTSB case key (mKey): 84847 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA12LA535 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/84847/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=84847 - Page: https://openairdocs.org/ntsb/ERA12LA535 ## Probable cause The pilot receiving instruction failed to maintain airplane control during the simulated engine-out landing. Contributing to the accident was the flight instructor's failure to take timely remedial action. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech 95-A55, 4 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=1152704), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/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 95-A55, 7 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1152704), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Beech 95-A55, 1 case](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=1152704), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Simulated/training event](https://openairdocs.org/ntsb-events/600); cases with it: [Beech 95-A55, 1 case](https://openairdocs.org/ntsb-events/600/sequence.md?model=1152704), [All aircraft, 173 cases](https://openairdocs.org/ntsb-events/600/sequence.md) - [Landing-flare/touchdown: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Beech 95-A55, 2 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1152704), [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: [Beech 95-A55, 6 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1152704), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot receiving instruction was conducting a simulated engine-out emergency landing when the accident occurred. Several eyewitnesses reported that the airplane began to roll to the left while it was in flight. One eyewitness reported hearing the airplane's engines increase in power. During postaccident interviews, the flight instructor stated that the left engine was at the idle power setting to simulate the engine failure for landing; however, he could not recall the events that took place during the accident sequence. Examination of the airframe and engines revealed no anomalies or malfunctions that would have precluded normal operation. Review of the private pilot’s medical history revealed nothing to suggest a medical cause for impairment or incapacitation. Therefore, it is likely that during the landing flare, the pilot receiving instruction added power to the right engine and failed to properly compensate for the increased asymmetrical thrust, which resulted in a loss of control. ## Factual narrative HISTORY OF FLIGHT On August 29, 2012, about 1445 eastern daylight time, a Beech 95-A55, N71BM, impacted the ground while landing at Millville Municipal Airport (MIV), Millville, New Jersey. The certificated flight instructor (CFI) sustained serious injuries, and the certificated private pilot receiving instruction was fatally injured. The airplane sustained substantial damage to the fuselage and all flight control surfaces. The airplane was registered to the pilot receiving instruction and was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed, and no flight plan was filed. Several eyewitnesses reported that the airplane appeared to have touched down on the runway before it veered to the left and "cart-wheeled" prior to coming to rest about 500 feet from the edge of the runway. Other witnesses reported that the airplane was approximately 20 feet above ground level, rolled to the left, climbed, then nosed over, impacted the ground, and "cart-wheeled." One eyewitness reported hearing the "engines power up," and then observed the airplane pitch up and to the left prior to impacting the ground in a nose-low attitude. According to a written statement by the CFI, the pilot receiving instruction was conducting a simulated engine-out emergency landing with the left engine at idle power when the accident occurred. However, the CFI at the time of this writing had no memory of the accident sequence. He stated that his last recollection of the accident was being over the runway threshold in the simulated engine-out landing configuration. PERSONNEL INFORMATION Flight Instructor The CFI, age 69, held a commercial pilot certificate with ratings for airplane single- and multiengine land and instrument airplane. He also held a flight instructor certificate with ratings for airplane single- and, multi-engine, and instrument airplane; as well as a flight engineer certificate with a rating for jet. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued September 1, 2011. He reported 2,729.9 total hours of flight experience, of which 35.8 hours were in the accident airplane make and model. His most recent flight review was conducted on July 24, 2011. Pilot Receiving Instruction The pilot receiving instruction, age 60, held a private pilot certificate with a rating for airplane single-engine land. His most recent FAA third-class medical certificate was issued August 25, 2010, and was not valid for any class after. The pilot's logbook was recovered and indicated 216.9 total hours of flight experience, of which 11.9 hours were in the accident airplane make and model. His most recent flight review was conducted on August 23, 2012. AIRCRAFT INFORMATION The airplane was a low-wing, multiengine, retractable tricycle gear airplane. It was equipped with two Continental Motors IO-470-L, 260-hp engines, and two Hartzell 2-bladedpropellers. According to FAA and airplane maintenance records, the airplane was manufactured in 1962 and registered to the owner on December 15, 2011. The airplane's most recent annual inspection was dated on July 1, 2012. At the time of the inspection, the reported aircraft total time was 3,813.8 hours. At the time of the inspection, the right engine had 1,771.8 hours since major overhaul and the left engine had 761.0 hours since major overhaul. METEOROLOGICAL INFORMATION The 1454 recorded weather observation at MIV included wind from 290 degrees at 5 knots, 10 miles visibility, clear skies, temperature 27 degrees C, dew point 13 degrees C; barometric altimeter 29.97 inches of mercury. COMMUNICATION At 1426:59, one of the pilots made initial contact with Millville Radio, which was monitored by personnel at Lockheed Martin Flight Service. The pilot subsequently reported that the airplane was 5 miles to the southwest of MIV, and was inbound for landing. At 1429:16, the pilot reported entering the downwind leg of the traffic pattern for runway 32. The final transmission recorded from the accident flight was at 1431:52, when the pilot stated "seven one bravo mike wilco we're uh simulate an engine out." AIRPORT INFORMATION MIV was a publicly-owned airport and at the time of the accident did not have an operating air traffic control tower; however, a flight service station was located on the airport at the time of the accident. The airport was equipped with two runways, designated as runway 10/28 and 14/32. The runways were reported as "in good condition" at the time of the accident. Runway 10/28 was 6,003-foot-long by 150-foot-wide and runway 14/32 was 5,058-foot-long by 150-foot-wide. The airport was 85 feet above mean sea level. WRECKAGE AND IMPACT INFORMATION Initial examination by an FAA inspector revealed that the initial ground scars were located approximately 115 feet from the side edge of the runway and the airplane came to rest about 300 feet from the ground scars and facing back to the direction of travel. One engine was located approximately 30 feet from the wreckage and the other engine was located under the airplane, both had been detached from the firewall. The left wingtip was bent in the positive direction, and the right wing exhibited crush damage. Flight control continuity was confirmed to all surfaces. During recovery of the airplane, approximately 62 gallons of fuel was removed from the fuel tanks. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot receiving instruction on August 31, 2012, by the City of Philadelphia Office of the Medical Examiners, Philadelphia, Pennsylvania. The autopsy findings listed the cause of death as "multiple blunt impact injuries" and the report listed the specific injuries. Toxicological testing was performed post mortem at the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The tests were negative for carbon monoxide, cyanide, and ethanol. Thefollowing drugs were detected in the specimens submitted for testing: - Atropine was detected in the Urine; however, was not detected in the Blood (Heart) - Clopidogrel was detected in the Urine; however, was not detected in the Blood (Heart) - Desmethylsildenafil was detected in the Urine and the Blood (Heart) - Etomidate was detected in the liver and the Blood (Heart) - Lorazepam was detected in the Muscle and the Blood (Heart) - Salicylate was detected in the Urine - Sildenafil was detectyed in the Blood (Heart) and the Urine - Trimethoprim was detected in the Blood (Heart) and the Urine. The toxicology results include some medications administered intravenously during hospital interventions: atropine (a Cardiac stimulant) and etomidate (a sedative/hypnotic). Oral medications ingested prior to the crash include clopidogrel (an antiplatelet medication used to prevent heart attacks and strokes), salicylate (also known as aspirin, an antiplatelet medication used to prevent heart attacks and strokes), and trimethoprim (an antibiotic used to prevent urinary tract infections after kidney transplant). The toxicological report also identified Lorazepam (a hypnotic benzodiazepine); however, it is unclear from the records if this was an oral medication administered prior to the accident, or given in the hospital. ADDITIONAL INFORMATION Engine Examination Both engines were sent to the manufacturer's facility in Mobile, Alabama for further examination. Both engines were mounted in a test stand and operated at varying power settings. During the tests, neither engine exhibited any signs of hesitations, malfunctions, or anomalies. A detailed examination report for both engines is located in the docket that accompanies this accident report. Airplane Flying Handbook (FAA-H-8083-3A) According to FAA publication FAA-H-8083-3A, Airplane Flying Handbook, Chapter 12, "Transition to Multiengine Airplanes" which states in part "Engine Inoperative Approach and Landing: The approach and landing with one engine inoperative is essentially the same as a two-engine approach and landing…the differences will be the reduced power available and the fact that the remaining thrust is asymmetrical…large, sudden power applications or reductions should also be avoided…the pilot must be prepared, however, for a rudder trim change as the power of the operating engine is reduced to idle in the roundout just prior to touchdown…" FAA Advisory Circular 61-21A FAA Advisory Circular 61-21A, states in part "Due to variations in performance, limitations, etc., of many light twins, no specific flightpath or procedure can be proposed that would be adequate in all engine-out approaches. In most light twins, however, a single-engine approach can be accomplished with the flight path and procedures almost identical to a normal approach and landing." ## Aircraft - Registration: [N71BM](https://openairdocs.org/deregistered/N71BM-2013-06-17), registration cancelled 2013-06-17, S/N TC-280, built 1962 (OpenAirDocs) - Reported make and model: BEECH 95-A55 - Registry model: [Beech 95-A55](https://openairdocs.org/model/beech-95-a55) (registry code 1152704) (OpenAirDocs) - Registry engine: [Continental IO-470 series](https://openairdocs.org/engine/continental-io-470-series) (registry code 17044, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TC-280 - Airframe hours: 3814 - Engines: CONT MOTOR IO-470-L 260 horsepower reciprocating; CONT MOTOR IO-470-L 260 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 1, 2012 - Departed: XLL, Allentown, NJ - Destination: VAY, Mt. Holly, NJ - Airport: MIV, Millville Municipal Airport, runway 32, 5,058 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 69; injuries: serious; flight instructor, commercial, flight engineer; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review July 24, 2011; seat: right; flight hours: 2,730 total, 36 in this make and model, 2,588 as pilot in command, 94 in the last 90 days, 23 in the last 30 days, 3 in the last 24 hours - Pilot; age 60; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review August 23, 2012; seat: left; toxicology performed; flight hours: 217 total, 12 in this make and model, 124 as pilot in command, 12 in the last 90 days, 12 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 290° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 55 °F - Altimeter: 29.96 inHg - Observed at: MIV ## 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 20120829020229A](https://openairdocs.org/incident/20120829020229A), Aug 29, 2012: Beech 95-A55, Millville, NJ, Destroyed, 1 fatal. On August 29, 2012, at approximately 1445 eastern daylight time, a Beech 95-A55, registration N71BM, impacted the ground while attempting to land on runway 32… ## Docket (17 files) The files NTSB released with the investigation on August 7, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=84847. 21.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - Certificated Flight Instructor (item 1, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380428&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20Certificated%20Flight%20Instructor-Redacted.PDF - Most Recent Annual Airplane Inspections (item 2, .PDF, 747 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40377684&FileExtension=.PDF&FileName=Most%20Recent%20Annual%20Airplane%20Inspections-Redacted.PDF - Student Pilot Logbook [Excerpts] (item 3, .PDF, 574 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395393&FileExtension=.PDF&FileName=Student%20Pilot%20Logbook%20%5BExcerpts%5D-Redacted.PDF - Transcript of Millville Radio (item 4, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40396224&FileExtension=.PDF&FileName=Transcript%20of%20Millville%20Radio-Master.PDF - Millville Weather (item 5, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376349&FileExtension=.PDF&FileName=Millville%20Weather-Master.PDF - Eyewitness Written Statements (item 6, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40396297&FileExtension=.PDF&FileName=Eyewitness%20Written%20Statements-Redacted.PDF - Memorandum of Record - Left Engine Examination (14 Embedded Photographs) (item 7, .PDF, 14 photos, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40396299&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20-%20Left%20Engine%20Examination%20(14%20Embedded%20Photographs)-Redacted.PDF - Memorandum of Record - Right Engine Examination (15 Embedded Photographs) (item 8, .PDF, 15 photos, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40396300&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20-%20Right%20Engine%20Examination%20(15%20Embedded%20Photographs)-Redacted.PDF - Reports from Local Agencies (item 9, .PDF, 220 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376530&FileExtension=.PDF&FileName=Reports%20from%20Local%20Agencies-Redacted.PDF - Statement of Party Representatives to NTSB Investigation - CMI (item 10, .PDF, 315 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376531&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20-%20CMI-Redacted.PDF - Medical Factual (item 11, .PDF, 149 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391722&FileExtension=.PDF&FileName=Medical%20Factual-Master.PDF - Toxicological Report (item 12, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395351&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 13, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40396098&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Evidence Control Form - ERA13LA535-IIC-001 and 002 - Acer Laptop and GPS (item 14, .PDF, 362 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40396222&FileExtension=.PDF&FileName=Evidence%20Control%20Form%20-%20ERA13LA535-IIC-001%20and%20002%20-%20Acer%20Laptop%20and%20GPS-Redacted.PDF - Photo 1: Airplane At Rest (Courtesy of the FAA) (item 15, .PDF, 5.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376526&FileExtension=.PDF&FileName=Photo%201%3A%20Airplane%20At%20Rest%20(Courtesy%20of%20the%20FAA)-Master.PDF - Photo 2: Left Engine At Rest (Courtesy of the FAA) (item 16, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376527&FileExtension=.PDF&FileName=Photo%202%3A%20Left%20Engine%20At%20Rest%20(Courtesy%20of%20the%20FAA)-Master.PDF - Photo 3: Right Engine At Rest (Courtesy of the FAA) (item 17, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376528&FileExtension=.PDF&FileName=Photo%203%3A%20Right%20Engine%20At%20Rest%20(Courtesy%20of%20the%20FAA)-Master.PDF From the NTSB's public API. 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