ERA19FA250

The pilot and the flight instructor were departing the airport. Shortly after takeoff, the pilot requested to return to the airport but did not state a reason for returning or declare an emergency. The tower controller cleared the airplane to land on any runway, provided the current wind information, and attempted to contact the pilot but received no response. A witness then observed the airplane in a nose low attitude as it descended into the trees below. The airplane impacted trees and terrain about 2 nautical miles from the airport and came to rest inverted in a nose-low attitude. The airplane sustained substantial damage to the wings, fuselage, and tail. Examination of the airframe, flight controls, engines, and engine accessories revealed no evidence of preimpact failures or malfunctions that would have precluded normal operation. The right fuel selector was found in the “main” position, while the left fuel selector was observed between the “main” and “crossfeed” positions. Both fuel selector valves were removed from the airplane, and air was blown through the valves to determine position. The right fuel selector valve was confirmed on the main (right) tank. The left fuel selector valve had no airflow when air was introduced through the crossfeed port. When air was blown through the main port, the airflow was restricted due to the position of the valve. Further, fuel was drained from the right fuel strainer and tested; no water was detected. No fuel was observed in the left fuel strainer. All fuel caps were observed closed and secured. The four fuel tanks were breached, and no fuel was observed. Based on this information, it is likely that during the flight one of the pilots inadvertently placed the valve between main and crossfeed positions. The fuel flow to the left engine was then restricted due to the intermediate position of the left fuel selector valve, which resulted in a loss of engine power. Additionally, examination of the airplane revealed that, for both engines, the throttles were found full forward, the mixture controls were set to rich, and the propeller controls were set to high rpm settings, which indicated that the pilots did not attempt to secure the left engine as described in the emergency checklist for engine failure after liftoff and in flight in the pilot operating handbook for the airplane make/model. Following the loss of engine power to the left engine, the airplane’s performance and handling characteristics would have been significantly degraded, and it is likely that the pilots lost control of the airplane while attempting to return to the airport. Postaccident toxicological testing of samples from the commercial pilot detected therapeutic levels of sertraline in his system. There was no evidence available to suggest that the use of this drug or any underlying condition that prompted the pilot’s use of it impacted his psychomotor performance during the flight.

The airplane was equipped with an optional fuel tank installation. The Beechcraft Baron B55 pilot’s operating handbook (POH), section VII, Systems Description – Fuel System, indicated that the optional fuel tank installation consisted of a 37-gallon main tank in each wing leading edge and a 31-gallon auxiliary tank in each wing panel outboard of the nacelle, for a total of 136 gallons of useable fuel (if all tanks were full). The POH further stated, “The separate, identical fuel supplies for each engine are interconnected by crossfeed lines. During normal operation each engine uses its own fuel pumps to draw fuel from its respective fuel tank arrangement. However, on emergency crossfeed operations the entire fuel supply of any or all tanks can be consumed by either engine.” The POH, section III, Emergency Procedure – Engine Failure, includes the following checklist for engine failure after lift-off and in flight: “An immediate landing is advisable regardless of take-off weight. Continued flight cannot be assured if take-off weight exceeds the weight determined from the TAKE-OFF WEIGHT graph. Higher take-off weights will result in a loss of altitude while retracing the landing gear and feathering the propeller. Continued flight requires immediate pilot response to the following procedures. Landing Gear and Flaps – UP Throttles (inoperative engine) – CLOSED Propeller (inoperative engine) – FEATHER Power (operative engine) – AS REQUIRED Airspeed – MAINTAIN SPEED AT ENGINE FAILURE (100 KTS (115 MPH) MAX.) UNTIL OBSTACLES ARE CLEARED After positive control of the airplane is established: Secure inoperative engine: Mixture Control – IDLE CUT-OFF Fuel Selector – OFF Fuel Boost Pump – OFF Magneto/Start Switch – OFF Generator/Alternator – OFF Cowl Flap – CLOSED Electrical Load – MONITOR (Maximum load of 1.0 on remaining engine). NOTE The most important aspect of engine failure is the necessity to maintain lateral and directional control. If airspeed is below 78 kts (90 mph), reduce power on the operative engine as required to maintain control.” On August 18, 2019, about 0851 eastern daylight time, a Beech 95-B55, N678DM, was substantially damaged when it was involved in an accident near Wilmington, Delaware. The pilot and the flight instructor were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The airplane was departing New Castle Airport (ILG), Wilmington, Delaware. Air traffic control radio communication data provided by the Federal Aviation Administration (FAA) indicated the pilot established communication with the tower controller at ILG, who cleared the airplane for takeoff from runway 32 and instructed the pilot make left traffic. About 1 minute later, the pilot advised that during takeoff, a door popped open. The controller instructed the pilot to make a 180° turn and back-taxi on runway 32. About 2 minutes later, the pilot requested to take off from runway 32, and the controllercleared the flight for takeoff. About 2 minutes later, the pilot advised the controller that he was returning to the runway; however, he did not specify a reason or declare an emergency. The controller cleared the flight to land on any runway. The controller then gave a wind check and attempted to contact the pilot but received no response. A witness driving on a nearby interstate reported that he saw the airplane “nose diving” and heading straight down into trees. The FAA Forensic Sciences Laboratory performed toxicology testing on the pilot’s tissue samples; sertraline and desnethylsertraline were detected in blood and urine specimens. Sertraline is an antidepressant in a group of drugs called selective serotonin reuptake inhibitors. Desmethylsertraline, also known as norsertraline, is an active metabolite of sertraline. Sertraline is a prescription medication indicated for the treatment of depression, post-traumatic stress disorder, panic disorder, social anxiety disorder and obsessive-compulsive disorder. Sertraline carries the warning that use may impair the mental and physical ability to perform hazardous tasks. The FAA Forensic Sciences Laboratory performed toxicology testing on the flight instructor’s tissue samples. The testing detected acetaminophen in the flight instructor’s urine. Acetaminophen, commonly marketed as Tylenol, is a fever-reducing and nonnarcotic pain medication and is not considered impairing. A review of the pilot’s logbook, which was recovered in the wreckage, indicated he had recorded about 586 total hours of flight experience, with 72 hours of multi-engine experience through the date of the last logbook entry on June 22, 2019. The flight instructor’s logbook was not recovered. On the application for his most recent second-class medical certificate, dated October 29, 2018, he reported 8,900 total hours of flight experience, including 115 hours in the previous 6 months. The accident site was located about 2.1 nautical miles northwest of the runway 32 threshold. Examination of the wreckage at the accident site revealed that the airplane impacted trees and then terrain in a nose-low and inverted attitude. An odor of 100LL aviation fuel was noted on site. Two sections of the right wing were separated and were found in a tree about 30 ft above the ground near the main wreckage. Flight control cable continuity was established from all control surfaces to the cockpit. The left and right aileron bellcranks displayed fracture features consistent with overload and all cable ends remained attached to their fittings. All three landing gear were retracted, and the landing gear switch was in the retracted position. The right fuel selector was found in the "main" position. The left fuel selector was found between the “main” and “crossfeed” positions. Both fuel selector valves were removed from the airplane, and air was blown through to determine position. The right fuel selector valve was confirmed on the main (right) tank. Theleft fuel selector valve had no airflow when air was introduced through the crossfeed port; when air was blown through the main port, airflow was restricted. Fuel was drained from the right fuel strainer and tested; no water was detected with a water-finding paste. No fuel was observed in the left fuel strainer. All fuel caps were found closed and secured. The four fuel tanks were breached and absent of fuel. For both the left and right engine, the throttles were found in the full forward position, the mixture controls were fully rich, and the propeller controls were at the high rpm settings. Both ignition switches were found in the “on” position. The left engine remained partially attached to the airframe through wires, hoses, and cables. There were no signs of a catastrophic internal engine failure. The crankshaft was rotated using a hand tool, and valvetrain continuity was established. After the cylinders were removed, the exposed portions of the crankshaft were visually inspected; the visible portions displayed normal operating and lubrication signatures. The fuel pump was functionally tested and capable of pumping fuel. The magnetos were tested and produced spark on all towers. The left propeller remained partially attached to the propeller flange; one propeller blade displayed minor chordwise scratches and the blade tip was bent about 90° forward. The other propeller blade was bent aft and was loose in the hub. The right engine remained partially attached to the airframe through cables, hoses, and wires. There were no signs of a catastrophic internal engine failure. The crankshaft was rotated using a hand tool, and valvetrain continuity was established. The fuel pump was functionally tested and capable of pumping fuel. The magnetos were tested and produced spark on all towers. The right propeller had almost completely pulled free from the crankshaft. One propeller blade displayed minor twisting and aft bending deformation. The other propeller blade displayed S-bending deformation.