# NTSB ERA20FA022: Beech 58, N959CM, Ocala, FL, October 31, 2019

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 3 · Field · Final report
- Date: October 31, 2019, 11:31 local (15:31 UTC)
- Place: Ocala, FL · Impacted a major highway
- Coordinates: 29.141666, -82.194168
- Nearby events: https://openairdocs.org/map.md?lat=29.1417&lon=-82.1942&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Defining event: [Initial climb: Medical event](https://openairdocs.org/ntsb-events/850)
- Highest injury: Fatal
- Injuries: 2 fatal, 1 serious; on the ground: 1 serious
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Eastern Region Aviation
- Parties: Continental Motors, Textron, FAA FSDO
- NTSB case key (mKey): 100509
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20FA022
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100509/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100509
- Page: https://openairdocs.org/ntsb/ERA20FA022

## Probable cause

The pilot’s failure to maintain control of the airplane due to an acute medical event and/or his use of impairing medications.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Raytheon 58, 2 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=7150003), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md)
- [Impairment/incapacitation](https://openairdocs.org/ntsb-findings/02012000): Personnel issues › Physical · Pilot (probable cause); cases with it: [Raytheon 58, 1 case](https://openairdocs.org/ntsb-findings/02012000/cases.md?model=7150003), [All aircraft, 40 cases](https://openairdocs.org/ntsb-findings/02012000/cases.md)
- [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Raytheon 58, 5 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=7150003), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Raytheon 58, 5 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7150003), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Initial climb: Medical event](https://openairdocs.org/ntsb-events/850) (defining event); cases with it: [Raytheon 58, 1 case](https://openairdocs.org/ntsb-events/850/sequence.md?model=7150003), [All aircraft, 63 cases](https://openairdocs.org/ntsb-events/850/sequence.md)
- [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Raytheon 58, 7 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7150003), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Raytheon 58, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=7150003), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md)

## Analysis

After experiencing an issue with a fluctuating fuel transducer on the right engine, the pilot hired a mechanic, who removed the fuel flow transducers from both engines and reinstalled them on the opposite engine to determine if there was an instrument indication problem or a fuel flow sensor issue. After performing the maintenance, the pilot and mechanic performed several ground runs of the engines without incident. They then departed on a local flight. Review of air traffic control communications revealed that the pilot initially taxied to the wrong runway, and after takeoff, failed to acknowledge multiple calls from the controller, did not follow the controller’s instructions, and thought that he was flying west when he was flying toward the east. About 2 minutes after takeoff, a transmission was received from the accident airplane requesting to return to the airport. The airplane impacted a four-lane divided highway and was consumed by a postcrash fire. Examination of the airplane, both engines, and their respective fuel transducers revealed no mechanical discrepancies that would have precluded normal operation. Autopsy of the pilot revealed severe abdominal aortic atherosclerotic disease, which increased his risk for an extra-cardiovascular event such as a stroke. Toxicology testing detected the impairing medication diazepam and its metabolite at the lower end of its therapeutic range in the pilot’s chest blood. Toxicology testing also revealed that the primary psychoactive compound of marijuana, THC, was detected in the pilot’s blood just above the laboratory’s detection limit. The THC concentration did not suggest recent use and it is unlikely that the pilot’s use of marijuana contributed to the accident. The circumstances of the accident indicate that the pilot did not perform in a manner consistent with his level of skill and experience, and it is likely that his loss of control was the result of physiological impairment; however, whether his impairment was the result of an acute medical event and/or his use of impairing medications could not be determined based on the available information.

## Factual narrative

On October 31, 2019, at 1131 eastern daylight time, a Beechcraft BE-58, N959CM, was destroyed when it was involved in an accident near Ocala, Florida. The private pilot and passenger were fatally injured. An individual on the ground was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 maintenance test flight. The pilot had flown into Ocala International Airport Jim Taylor Field (OCF), Ocala, Florida, the day before the accident with a friend. According to the friend, the flight was normal, but the right engine’s fuel flow meter was fluctuating between zero and high while the other engine instruments were normal. The following day, the pilot asked a mechanic to look at the fuel transducer. The mechanic removed the fuel flow transducers from both engines and reinstalled them on the opposite engine to determine if there was an instrument indication problem or an actual fuel flow sensor issue. After performing the maintenance, the pilot and mechanic performed several test runs of the engines without incident. They then conducted a flight test together. A review of air traffic control communications provided by the Federal Aviation Administration (FAA) revealed that the pilot requested a taxi clearance at 1124 and asked if there was a block of airspace near the airport where he could conduct a maintenance test flight. The ground controller told the pilot that there were no restricted areas and he could choose where he would like to go. The pilot responded that he would conduct the test west of the airport. The ground controller cleared the pilot to taxi to runway 18; however, the pilot initially taxied to runway 26 and the ground controller twice provided the pilot directions to runway 18. After takeoff, the pilot was cleared to make a right turn to the west, which he did not acknowledge. Several seconds later, the controller repeated the clearance, which the pilot again did not acknowledge, and the pilot turned left onto an easterly heading. On the third attempt to contact the pilot, the controller asked if he was “alright” and the pilot responded, “say again.” The controller asked where the pilot was going and the pilot reported that he was going to the west; the controller stated “no, you’re not, you’re heading to the east sir.” The controller again issued instructions to the pilot to proceed on course to the west; the pilot did not acknowledge. Seeing that the airplane was continuing to the east, the controller asked the pilot his intentions. Several seconds later, about 2 minutes after takeoff, the accident airplane transmitted, “niner charlie mike, we need to return to the field sir.” This was the last communication from the airplane. Numerous witnesses saw the airplane after it departed. Some of these witnesses said it was flying north at a low altitude before it entered a steep inverted dive. Other witnesses reported the airplane spinning to the left as it descended. One witness said that theairplane was on fire, while another witness said that the left propeller was not turning. Data downloaded from a handheld GPS found in the wreckage revealed that, after takeoff, the airplane entered a left turn and never gained more than 418 ft in altitude. During the last minute of flight, the airplane’s groundspeed varied from 95 to 107 knots before the data ended at 1131. Video recovered from a parked car near the accident site captured the airplane rotating counterclockwise as it impacted a four-lane divided highway. The airplane’s right wing struck the ground first before impacting a moving vehicle. The airplane then skidded across two lanes of traffic, struck a concrete curb, then spun 180° before coming to rest in a vacant lot. The deflection of the rudder just before ground impact was estimated to be 20º±4º to the left, in the direction of rotation. No airframe or engine fire and/or smoke was observed in the video. (see figure 1.) Figure 1 Screen Capture of Automobile Video Showing Airplane Just Prior to Impact. PERSONNEL INFORMATION The pilot held a private pilot certificate with ratings for airplane multiengine land, airplane single-engine land, airplane single-engine sea, and instrument airplane. According to the pilot’s logbook, he had accumulated about 7,800 total hours of flight experience and completed a flight review on October 4, 2019. On February 19, 2019, he was issued a Federal Aviation Administration (FAA) third class medical certificate with a limitation for corrective lenses. WRECKAGE AND IMPACT INFORMATION On-scene examination revealed that the airplane traveled about 150 ft from the initial impact point. All major components of the airplane were located at the accident site and a postimpact fire consumed the fuselage. Continuity of the ailerons, elevator, and rudder was established from each of the respective control surfaces to the cockpit. The flaps and landing gear were retracted. Located near the initial impact point was a ground scar that was consistent with an imprint of the airplane’s nose, fuselage, both engines, both propellers and both wings. Three distinct slash marks, consistent with propeller contact, was observed in the asphalt near where the right engine impacted the road. Another slash mark was observed adjacent to where the left engine impacted the road. Both wings sustained impact damage and their respective fuel tanks were breached. The fuel selector handle and the valves for each wing fuel tank were found in the “on” position. The left engine remained attached to the airframe and sustained extensive impact and thermal damage. The crankshaft was capable of rotation; however, due to impact damage to the camshaft gear, it could not be rotated completely. Subsequent borescope examination of the engine, pistons, and cylinders revealed no anomalies. The throttle metering assembly was damaged by thermal and impact forces. Examination revealed that the throttle control arm was installed backward from thenormal position; however, the throttle and metering assembly spring was intact, held tension, and operated normally. No additional anomalies were discovered on the engine or components that would preclude normal engine operation. The three-bladed propeller assembly sustained extensive impact damage and a portion of the hub remained attached to the crankshaft. One blade remained attached to the hub, and the second and third blades had separated and were found with the wreckage. The blade that remained attached displayed chordwise scratches and curling at the tip. Of the two blades that separated, one exhibited twisting deformation, leading-edge gouges, and chordwise scratches. The other blade exhibited minor chordwise scratches near the blade tip and minor twisting deformation. The fuel flow transducer remained attached to its installation point and displayed thermal damage. The fuel flow inlet nut was finger-tight and able to be moved by hand; however, the fuel line and nut displayed thermal damage. The transducer was removed and examined; air was blown into the inlet and it flowed through the transducer freely. Disassembly of the transducer revealed no obstructions or other anomalies. The right engine separated from the airframe and was found just forward of the right wing. Due to impact and thermal damage, the crankshaft could not be rotated. The engine was completely disassembled, which revealed no preimpact anomalies that would have precluded normal operation. The three-bladed propeller assembly sustained significant impact damage. One blade remained partially attached to the hub and exhibited chordwise scratches, forward deformation, and tip curling. The other two blades had separated and were found with the wreckage. Of the two blades that separated, one had a large portion of the tip missing in addition to chordwise scratches, leading-edge gouges, twisting and S-bending deformation. The blade and a recovered portion of the blade tip displayed chordwise scratches, twisting and forward bending deformation, and leading edge gouges. The other blade was also missing a tip of the blade and exhibited chordwise scratches, leading edge gouges, and displayed twisting and S-bending deformation. The fuel flow transducer remained attached to its installation point and remained relatively intact. The transducer was removed and examined; air was blown into the inlet and it flowed through the transducer freely. Disassembly of the transducer revealed no obstructions or other anomalies. MEDICAL AND PATHOLOGICAL INFORMATION The Medical Examiner Districts 5 & 24, Leesburg, Florida, performed an autopsy on the pilot. The cause of death was multiple blunt force injuries. Severe abdominal aortic atherosclerosis was identified. The FAA’s Forensic Sciences Laboratory performed toxicology testing on the pilot’s tissue and blood samples, which identified diazepam (commonly marketed as Valium) and its psychoactive metabolites nordiazepam and oxazepam in the pilot’sliver and muscle tissue. The non-sedating high blood pressure medication valsartan was also detected in liver and muscle. Toxicology testing performed for the medical examiner’s office detected diazepam at 96 nanograms per milliliter (ng/mL), nordiazepam at 94 ng/mL, and delta-9- tetrahydrocannabinol (THC) at 0.69 ng/mL in the pilot’s chest blood. Diazepam is a sedating benzodiazepine available by prescription as a controlled substance and used to treat anxiety and is also useful to help treat muscle spasms, alcohol withdrawal, and seizures. It is metabolized to the active metabolites nordiazepam or temazepam. These compounds are further metabolized to the active metabolite oxazepam. Diazepam and its metabolites carry the warning that they may impair the mental and physical ability to perform hazardous tasks. The therapeutic range of diazepam and nordiazepam is 100 to 2,000 ng/mL in the blood. Diazepam has a half-life of 21 to 82 hours; nordiazepam has a half-life of 25 to 200 hours. The marijuana plant (cannabis) contains chemicals called cannabinoids; THC is the primary psychoactive cannabinoid compound. THC's mood-altering effects include euphoria and relaxation. In addition, marijuana causes alterations in motor behavior, perception, and cognition. Significant performance impairments are usually observed for at least 1-2 hours following marijuana use, and residual effects have been reported up to 24 hours. THC is rapidly metabolized, but the rate of metabolism is not linear and depends on the means of ingestion (smoking, oil, and edibles), potency of the product, frequency of use, and user characteristics. THC is fat soluble, so is stored in fatty tissues and can be released back into the blood long after consumption. So, while the psychoactive effects may last a few hours, THC can be detected in the blood for days or weeks. Thus, low blood level test results do not necessarily reflect recent use and cannot be used to prove that the user was under the influence of the drug at the time of testing.

## Aircraft

- Registration: [N959CM](https://openairdocs.org/deregistered/N959CM-2020-05-18), registration cancelled 2020-05-18, S/N TH-1792, built 1996 (OpenAirDocs)
- Reported make and model: Beech 58 (Undesignat)
- Registry model: [Raytheon 58](https://openairdocs.org/model/raytheon-58) (registry code 7150003) (OpenAirDocs)
- Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: TH-1792
- Year built: 1996
- Airframe hours: 1979
- Engines: Continental IO-550-C31B 300 horsepower reciprocating; Continental IO-550-C31B 300 horsepower reciprocating
- Damage: Destroyed
- Fire: On-Ground
- Flight: Flight test, Part 91
- Operator: Caribbean World Resorts Ltd
- Registered owner: Caribbean World Resorts Ltd
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, March 18, 2019, 61 hours before
- Departed: OCF, Ocala, FL
- Destination: OCF, Ocala, FL
- Airport: OCF, Ocala Intl-Jim Taylor Field, runway 18, 7,467 × 150 ft, asphalt
- Equipment: Auto-pilot, Electronic multifunction display, Handheld GPS

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 73; injuries: fatal; private; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review October 4, 2019; seat: left; restraint: 3-point; toxicology performed; flight hours: 7,800 total

## Weather

- Conditions: Visual (VMC), Day
- Wind: 200° at 7 knots
- Visibility: 10 statute miles
- Temperature: 84 °F, dew point 75 °F
- Altimeter: 30.05 inHg
- Observed at: OCF, 2 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 20191031023279A](https://openairdocs.org/incident/20191031023279A), Oct 31, 2019: Raytheon Aircraft Company 58, Ocala, FL, Destroyed, 2 fatal. On October 31 2019 approximately 11:15 EST local, time N959CM a Beechcraft 58 baron with pilot/ aircraft owner and mechanic took off from Ocala International…

## Docket (18 files)

The files NTSB released with the investigation on November 16, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100509. 4.8 GB in all.

- Police narrative (includes witnesses) (item 1, PDF, 12 pages, 11.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11568174&FileExtension=pdf&FileName=Police%20Narrative%20and%20Witnesses_Redacted-Rel.pdf
- NTSB record of conversations (item 2, PDF, 3 pages, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11547258&FileExtension=pdf&FileName=Record%20of%20Conversation_Family%20and%20Friend-Rel.pdf
- Email communication with primary maintenance facility (item 3, PDF, 2 pages, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11547538&FileExtension=pdf&FileName=Email%20Communication%20with%20Primary%20Maintenance%20Facility_Redacted-Rel.pdf
- Airplane maintenance logbook excerpts (item 4, PDF, 14 pages, 152 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11549676&FileExtension=pdf&FileName=Airframe%20Propeller%20and%20Engine%20Maintenance%20Logbooks%20Excerpt_Redacted-Rel.pdf
- Fct air traffic control communications chronological summary excerpt (courtesy of FAA) (item 5, PDF, 1 page, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11551798&FileExtension=pdf&FileName=FCT%20Air%20Traffic%20Control%20Communications%20Chronological%20Summary%20Excerpt%20(Courtesy%20of%20FAA)-Rel.pdf
- FAA control tower recording ground control (courtesy of FAA) (item 6, WAV, 101 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11553028&FileExtension=wav&FileName=19-001-OCF-FCT%20%20GC%20-%20N959CM%2010-31-2019-Rel.wav
- FAA control tower recording local controller (courtesy of FAA) (item 7, WAV, 425 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11552757&FileExtension=wav&FileName=19-001-OCF-FCT%20LC%20-%20N959CM%20%2010-31-2019-Rel.wav
- Electronic devices specialist's factual report (item 8, PDF, 4 pages, 3 photos, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11551463&FileExtension=pdf&FileName=ERA20FA022_FactualReport_Final-Rel.pdf
- Electronic devices specialist's factual report - attachment 1 (item 9, CSV, 2 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11418549&FileExtension=csv&FileName=Attachment1-Rel.csv
- NTSB video study (item 10, PDF, 8 pages, 906 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11423875&FileExtension=pdf&FileName=Ocala%20Video%20Study%20final-Rel.pdf
- Car camera video of accident (item 11, MP4, 27.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9777895&FileExtension=mp4&FileName=2019-10-31_11-30-26-back-Rel.mp4
- Airport security camera video_prior to taxi (item 12, AVI, 2.0 GB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11553070&FileExtension=avi&FileName=Engine%20Run%20Prior%20to%20Taxi-Rel.avi
- Airport security camera video_taxi and takeoff (item 13, AVI, 2.0 GB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11553816&FileExtension=avi&FileName=Taxi%20Out%20Takeoff%20and%20Initial%20Climb-Rel.avi
- Photo array_accident site and damage (item 14, PDF, 11 pages, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11567898&FileExtension=pdf&FileName=Accident%20Site%20and%20Damage%20Photographs-Rel.pdf
- Medical case review_factual (item 15, PDF, 4 pages, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11415038&FileExtension=pdf&FileName=ERA20FA022_Ocala_FL_Medical_Factual_FINAL_081720-Rel.pdf
- Toxicological reports_pilot and A&P mechanic passenger (item 16, PDF, 6 pages, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11554021&FileExtension=pdf&FileName=Toxicology%20Reports_Pilot%20and%20A%26P%20Mechanic%20Passenger_Redacted-Rel.pdf
- Party forms_Textron and Continental (item 17, PDF, 11 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11558427&FileExtension=pdf&FileName=Party%20Forms_Textron%20and%20Continental_Redacted-Rel.pdf
- Wreckage release and evidence control forms (item 18, PDF, 5 pages, 252 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11601580&FileExtension=pdf&FileName=Wreckage%20Release%20and%20Evidence%20Control%20Forms_Redacted-Rel.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.

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