FTW02FA113

NTSB accident investigation · Beech D-45 · Minden, LA · April 6, 2002

Accident · FatalField investigationFinal report
Date
April 6, 2002, 15:33 local (21:33 UTC)
Place
Minden, LA
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N6VYBeech D-45
Weather
Visual (VMC) · Day
Status
Completed · report December 30, 2003
Report
Approved by Office Director
Parties
Raytheon Aircraft Company, Teledyne Continental Motors, FAA FSDO, Materials Analysis, Inc.
FAA report
20020406007429A
Case key
54469

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The private pilot's failure to maintain aircraft control during a go-around. Contributing factors were the private pilot's impairment due to drugs, the pilot-rated passenger's lack of experience in the airplane, and the prevailing gusty crosswind conditions.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightGo-around (vfr)
Weather condition - crosswindFactor
Impairment(drugs)Pilot in commandFactor
Aircraft control - not maintainedPilot in commandCause
Weather condition - gustsFactor
Aircraft handling - not possiblePilot passenger
Lack of total experience in type of aircraftPilot passengerFactor
In flight collision with objectDescent - uncontrolled
Object - tree(s)
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The airplane impacted wooded terrain west of the runway following an uncontrolled descent from a go-around from runway 01. Strong gusty winds (15 to 25 knots) from the east prevailed at the airport at the time of the accident. The private pilot, who occupied the front seat, had accumulated a total of 1,012.3 hours in the accident airplane. The pilot rated passenger, who occupied the aft seat, had accumulated a total of 321.5 hours, with none in the accident airplane. Review of the private pilot's personal and FAA medical records indicated that he had an essential tremor, a condition that caused his head and hands to shake noticeably, and not associated with any other disease. He continued to have progressive symptoms even on medications. He had an episode of unusual behavior, possibly related to his medications, in 1996 which occurred during operation of an aircraft. At the time of the accident, the private pilot was on fairly large doses of diazepam and propanolol to treat his essential tremor, medications which he did not note on his most recent application for a medical certificate in 2000 . The FAA medical records indicated that the FAA did not consider the private pilot medically qualified in 1996 and in 2000. Toxicological tests for the private pilot were positive for: diazepam (0.393 ug/ml) and its metabolites in blood and for propanolol in the blood and liver. Diazepam and its metabolites have substantial adverse effects on judgment, alertness, and performance. The pilot, in fact, complained of sedation from the diazepam, and adverse performance effects would be expected at the levels used. Propanolol which lowers blood pressure and reduces heart rate response to stress, may result in dizziness, fatigue, and decreased G-tolerance, particularly at high doses. The private pilot was impaired from the diazepam, possibly from propanolol, and possibly from his essential tremor. No evidence of uncorrected discrepancies was found in the maintenance records. No evidence of an in-flight mechanical and/or flight control malfunction was found that would have rendered the airplane uncontrollable prior to the impact.

Factual narrative

History of flight

On April 6, 2002, approximately 1533 central standard time, a Beech D-45 single-engine airplane, N6VY, impacted heavily wooded terrain following a loss of control during a go-around at the Minden-Webster Airport (F24), near Minden, Louisiana. The airplane was owned and operated by the private pilot under 14 Code of Federal Regulations Part 91. Both the private pilot, who occupied the front seat, and the pilot rated passenger, who occupied the aft seat, were fatally injured. The airplane was substantially damaged. Visual meteorological conditions prevailed for the local flight for which a flight plan was not filed. The personal flight departed F24 approximately 30 minutes prior to the accident.

Witnesses, local authorities, and acquaintances reported that both pilots were in the process of moving to Minden. The private pilot (front seat) had recently accepted a position with a local hospital, and the pilot rated passenger (aft seat) had a part time position as the airport manager for the City of Minden. The airplane had been in a hangar at the airport for several days, during which time the pilots had become acquainted and discussed flying the airplane.

The airplane was observed departing from runway 01, and subsequently departed the traffic pattern. The was observed by some of the witnesses at the airport performing a series of maneuvers at approximately 2,000 to 3,000 feet above the airport.

The airplane was then observed entering the traffic pattern, and performed a series of touch and goes on runway 01. Some of the witnesses observed that the pilot was having problems with correcting for the prevailing right crosswind. During their fourth approach, the aft seat pilot radioed to the Unicom operator and requested that she "come out and watch his landing." During the fourth approach, the airplane was observed drifting to the west of centerline with the flaps fully extended. Witnesses reported that the airplane stalled, and full power was heard being applied. The nose of the airplane was reported to pitch-up, as the airplane rolled into a 90-degree bank to the left. Subsequently, the airplane assumed a nose low attitude and descended uncontrolled to the ground. Witnesses reported hearing the sound of engine noise until ground impact.

Personnel information

The private pilot held the airplane single-engine land rating issued on November 13, 1982. According to the logbook, reviewed by the NTSB investigator-in-charge (IIC), the private pilot's accumulated flight time from December 29, 1985, through February 23, 2001, was 1,012.3 hours in the accident airplane. On July 26, 2000, the FAA medical examiner issued the private pilot a third class medical certificate with the limitation: Holder shall wear correcting glasses while exercising the privileges of his airman certificate.

The pilot rated passenger held the FAA commercial pilot certificate with the airplane single-engine land and instrument ratings. He held private pilot privileges for the multiengine land airplane. On June 5, 2001, he was issued the flight instructor certificate with the airplane single engine rating. On April 2, 2001, the pilot was issued a first class medical certificate without limitations. The pilot rated passenger's accumulated flight time was 321.5 hours with zero time in the accident airplane.

Aircraft information

The 1955 Beech D45 ( military T-34B), serial number BG-221 (military 140887) airplane was equipped with the Continental O-470-4 reciprocating engine (serial number 116057) rated at 225 horsepower with a Beech model 278-102 two bladed propeller (serial number 1496) installed.

Maintenance records indicated a total airframe time of 11,142.3 hours verified from military records dated August 1964, and the annual inspection performed on July 10, 1980. The airplane (N3565G) was issued the FAA airworthiness certificate on July 11, 1980. Registration (N6VY) to the current owner was dated November 22, 1983.

On December 12, 1996, the engine was removed from N6VY for a major overhaul and reinstalled at 0.00 time. On September 1, 2001, the last annual inspection was performed at the accumulated airframe time of 12,251.3 hours and an engine time of 118.6 since major overhaul (SMOH).

According to the City of Minden aviation fueling records, the airplane was refueled with 29.4 gallons of aviation fuel on March 15, 2002.

Meteorological information

At 1456, the weather observation facility at Shreveport (SHV), Louisiana, approximately 29 nautical miles northeast of the accident site, reported the wind 130 degrees at 8 knots, ceiling 13,000 scattered, 16,000 broken, visibility 10 statute miles, and the altimeter setting 30.16 inches Mercury.

Witnesses and local authorities reported the wind at the accident site was from the east at 10 knots gusting to 20 knots.

Aerodrome information

The airport (F24), located approximately 2 miles northwest of Minden, is owned and operated by the City of Minden, Minden, Louisiana. F24, is a non-towered airport with runway 01/19. Runway 01/19 is an asphalt runway, 5,001 feet long and 75 feet wide. Runway 01 elevation is 278 feet, and the runway 01 has obstructions (45-foot trees, 8:1 slope to clear) 300 feet left of the runway centerline.

Wreckage and impact information

The Global Positioning System (GPS) location of the accident site was 32 degrees 38.59 minutes North; 093 degrees 17.90 minutes West. The airplane was found in a nose low attitude (approximately 80 degrees) on a measured magnetic heading of heading of 130 degrees in the wooded area 967 feet west of the centerline of runway 01, 1,521 feet from the departure end of runway 01, and 930 feet from the left edge of runway 01. The ground crater measured approximately 5 feet wide and 2 1/2 feet deep. The landing gear was found in the extended position, and the flaps were retracted. Both cockpits and instrument panels were destroyed. The leading edge of the left wing, and the inboard leading edge of the right wing were crushed toward the wing spars. The integrity of the fuel system was compromised. Flight control continuity was confirmed for the elevators and rudder. The propeller was found separated from the engine. One propeller blade was straight, and one propeller blade had nicks along the outboard trailing edge. The airplane was recovered to a hangar at the airport (F24) for further examination.

The fuel gascolator was examined and no debris was found on the fuel screen. The stall warning system was tested at the wing and found operational. According to the aircraft representative, the aileron tab was found 2 degrees tab up (aileron down), the elevator tab 2 degrees tab down (elevator up), and the rudder 1 degree tab left (nose right). The front and rear engine throttle controls were found full forward, and the propeller control position mid-range. The aileron flight control assembly components (forward and aft torque tube support bracket, aileron bellcrank arm actuator, and the aft flight control stick tube were found fractured in the flight control system and were retained by the Board for further examination.

The engine crankshaft was rotated and continuity was confirmed to all the cylinders and to the accessory gears at the rear of the engine. Hand compression and valve action was noted on all the cylinders. The oil pump rotated. The generator rotated. The oil sump and screen were examined and no debris was found on the oil screen.

The Bendix model RS-5BD-1 throttle body/metering unit (part number 25243534, serial number 3897) had the fuel injector separated from the unit. The throttle valve was attached and in the idle position. The fuel valve and mixture control were free to move. The Bendix model LS6LN-28, part number 10-52350-20, serial number 9090511 (right), serial number 9051263 (left) magnetos exhibited impact

Aircraft

Registration
N6VY
Reported as
Beech D-45
Category
Airplane
Serial number
BG221
Airframe hours
12,251.3
Engine
Continental E-0-470-4, 225 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Stanley D. Pinder
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
Annual · September 1, 2001
Departed
F24 · Minden, LA
Airport
F24 · Minden-Webster, runway 01, 5,001 × 75 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
63
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 2, Invalid Medical for flight
Seat
Front
Toxicology
Performed
Flight hours
1,012 total · 1,012 in this make and model · 901 as pilot in command
Role
Pilot
Age
22
Injuries
Fatal
Certificates
Commercial, Private, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
June 5, 2001
Seat
Rear
Toxicology
Performed
Flight hours
322 total · 0 in this make and model · 284 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
90° at 10 knots, gusting 20
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 36 °F

Docket · 33

The files NTSB released with the investigation on November 13, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 27.8 MB in all.

Witness StatementsItem 1 · .PDF · 519 KBMedical Records Factual InformationItem 2 · .PDF · 13 KBMetallurgical Report from Materials Analysis, Inc.Item 3 · .PDF · 21 photos · 8.1 MBWreckage DiagramItem 4 · .PDF · 520 KBReports from Parties to the Investigation (Teledyne Continental)Item 5 · .PDF · 4.4 MBReports from Parties to the Investigation (Precision Airmotive)Item 6 · .PDF · 160 KBRefueling RecordsItem 7 · .PDF · 108 KBPortions of Private Pilot RecordsItem 8 · .PDF · 3.3 MBPortions of Maintenance RecordsItem 9 · .PDF · 2.0 MBStatement of Party Representatives to NTSB InvestigationItem 10 · .PDF · 412 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 11 · .PDF · 262 KBToxicological ReportsItem 12 · .PDF · 113 KBPhoto 01: View of cockpit and impact crater.Item 13 · .PDF · 730 KBPhoto 02: View of right wing.Item 14 · .PDF · 757 KBPhoto 03: View of left wing.Item 15 · .PDF · 776 KBPhoto 04: View of aircraft.Item 16 · .PDF · 851 KBPhoto 05: View of aircraftItem 17 · .PDF · 789 KBPhoto 06: View of propeller blade.Item 18 · .PDF · 601 KBPhoto 07: View of engine.Item 19 · .PDF · 689 KBPhoto 08: View of left wing.Item 20 · .PDF · 155 KBPhoto 09: View of engine.Item 21 · .PDF · 202 KBPhoto 10: View of aircraft. Courtesy of Continental.Item 22 · .PDF · 215 KBPhoto 11: View of right wing. Courtesy of Continental.Item 23 · .PDF · 193 KBPhoto 12: View of instrument panel. Courtesy of Continental.Item 24 · .PDF · 260 KBPhoto 13: View of engine. Courtesy of Continental.Item 25 · .PDF · 242 KBPhoto 14: View of fuel manifold. Courtesy of Continental.Item 26 · .PDF · 220 KBPhoto 15: View of propeller blade. Courtesy of Continental.Item 27 · .PDF · 277 KBPhoto 16: View of propeller. Courtesy of Continental.Item 28 · .PDF · 270 KBPhoto 17: View of flight control sticks. Courtesy of Continental.Item 29 · .PDF · 148 KBPhoto 18: View of fuel injector. Courtesy of Continental.Item 30 · .PDF · 156 KBPhoto 19: View of fuel pump. Courtesy of Continental.Item 31 · .PDF · 92 KBPhoto 20: View of magnetos. Courtesy of Continental.Item 32 · .PDF · 174 KBPhoto 21: View of propeller governor. Courtesy of Continental.Item 33 · .PDF · 126 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.