# NTSB FTW02FA113: Beech D-45, N6VY, Minden, LA, April 6, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 6, 2002, 15:33 local (21:33 UTC) - Place: Minden, LA - Coordinates: 32.643054, -93.298332 - Nearby events: https://openairdocs.org/map.md?lat=32.6431&lon=-93.2983&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report December 30, 2003 - Report: Approved by Office Director - Parties: Raytheon Aircraft Company, Teledyne Continental Motors, FAA FSDO, Materials Analysis, Inc. - NTSB case key (mKey): 54469 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW02FA113 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54469/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54469 - Page: https://openairdocs.org/ntsb/FTW02FA113 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, go-around (vfr) - weather condition - crosswind (contributing factor) - impairment(drugs), pilot in command (contributing factor) - aircraft control - not maintained, pilot in command (cause) - weather condition - gusts (contributing factor) - aircraft handling - not possible, pilot passenger - lack of total experience in type of aircraft, pilot passenger (contributing factor) - In flight collision with object, descent - uncontrolled - object - tree(s) - In flight collision with terrain/water, descent - 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](https://openairdocs.org/deregistered/N6VY-2002-08-28), registration cancelled 2002-08-28, S/N BG-221 (OpenAirDocs) - Reported make and model: Beech D-45 - Registry model: [Beech D-45](https://openairdocs.org/model/beech-d-45) (registry code 1152012) (OpenAirDocs) - Category: Airplane - Serial number: BG221 - Airframe hours: 12251.3 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: fatal; 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 - Pilot; age 22; injuries: fatal; 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 ## 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 20020406007429A](https://openairdocs.org/incident/20020406007429A), Apr 6, 2002: Beech D45, Minden, LA, No damage, 2 fatal. (-23) Passenger, invited aboard for a familiarization flight, announced intention for modified traffic pattern prior to fourth touch and go. An apparent… ## Docket (33 files) The files NTSB released with the investigation on November 13, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54469. 27.8 MB in all. - Witness Statements (item 1, .PDF, 519 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429357&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Medical Records Factual Information (item 2, .PDF, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40168970&FileExtension=.PDF&FileName=Medical%20Records%20Factual%20Information-Master.PDF - Metallurgical Report from Materials Analysis, Inc. (item 3, .PDF, 21 photos, 8.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429359&FileExtension=.PDF&FileName=Metallurgical%20Report%20from%20Materials%20Analysis,%20Inc.-Redacted.PDF - Wreckage Diagram (item 4, .PDF, 520 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200591&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Reports from Parties to the Investigation (Teledyne Continental) (item 5, .PDF, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429360&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20(Teledyne%20Continental)-Redacted.PDF - Reports from Parties to the Investigation (Precision Airmotive) (item 6, .PDF, 160 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200590&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20(Precision%20Airmotive)-Master.PDF - Refueling Records (item 7, .PDF, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429361&FileExtension=.PDF&FileName=Refueling%20Records-Redacted.PDF - Portions of Private Pilot Records (item 8, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429362&FileExtension=.PDF&FileName=Portions%20of%20Private%20Pilot%20Records-Redacted.PDF - Portions of Maintenance Records (item 9, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429363&FileExtension=.PDF&FileName=Portions%20of%20Maintenance%20Records-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 412 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429364&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 262 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429365&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Reports (item 12, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429366&FileExtension=.PDF&FileName=Toxicological%20Reports-Redacted.PDF - Photo 01: View of cockpit and impact crater. (item 13, .PDF, 730 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200678&FileExtension=.PDF&FileName=Photo%2001%3A%20View%20of%20cockpit%20and%20impact%20crater.-Master.PDF - Photo 02: View of right wing. (item 14, .PDF, 757 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200679&FileExtension=.PDF&FileName=Photo%2002%3A%20View%20of%20right%20wing.-Master.PDF - Photo 03: View of left wing. (item 15, .PDF, 776 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200680&FileExtension=.PDF&FileName=Photo%2003%3A%20View%20of%20left%20wing.-Master.PDF - Photo 04: View of aircraft. (item 16, .PDF, 851 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200681&FileExtension=.PDF&FileName=Photo%2004%3A%20View%20of%20aircraft.-Master.PDF - Photo 05: View of aircraft (item 17, .PDF, 789 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200682&FileExtension=.PDF&FileName=Photo%2005%3A%20View%20of%20aircraft-Master.PDF - Photo 06: View of propeller blade. (item 18, .PDF, 601 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200683&FileExtension=.PDF&FileName=Photo%2006%3A%20View%20of%20propeller%20blade.-Master.PDF - Photo 07: View of engine. (item 19, .PDF, 689 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200684&FileExtension=.PDF&FileName=Photo%2007%3A%20View%20of%20engine.-Master.PDF - Photo 08: View of left wing. (item 20, .PDF, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200685&FileExtension=.PDF&FileName=Photo%2008%3A%20View%20of%20left%20wing.-Master.PDF - Photo 09: View of engine. (item 21, .PDF, 202 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200686&FileExtension=.PDF&FileName=Photo%2009%3A%20View%20of%20engine.-Master.PDF - Photo 10: View of aircraft. Courtesy of Continental. (item 22, .PDF, 215 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200687&FileExtension=.PDF&FileName=Photo%2010%3A%20View%20of%20aircraft.%20Courtesy%20of%20Continental.-Master.PDF - Photo 11: View of right wing. Courtesy of Continental. (item 23, .PDF, 193 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200688&FileExtension=.PDF&FileName=Photo%2011%3A%20View%20of%20right%20wing.%20Courtesy%20of%20Continental.-Master.PDF - Photo 12: View of instrument panel. Courtesy of Continental. (item 24, .PDF, 260 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200689&FileExtension=.PDF&FileName=Photo%2012%3A%20View%20of%20instrument%20panel.%20Courtesy%20of%20Continental.-Master.PDF - Photo 13: View of engine. Courtesy of Continental. (item 25, .PDF, 242 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200690&FileExtension=.PDF&FileName=Photo%2013%3A%20View%20of%20engine.%20Courtesy%20of%20Continental.-Master.PDF - Photo 14: View of fuel manifold. Courtesy of Continental. (item 26, .PDF, 220 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200691&FileExtension=.PDF&FileName=Photo%2014%3A%20View%20of%20fuel%20manifold.%20Courtesy%20of%20Continental.-Master.PDF - Photo 15: View of propeller blade. Courtesy of Continental. (item 27, .PDF, 277 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200692&FileExtension=.PDF&FileName=Photo%2015%3A%20View%20of%20propeller%20blade.%20Courtesy%20of%20Continental.-Master.PDF - Photo 16: View of propeller. Courtesy of Continental. (item 28, .PDF, 270 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200694&FileExtension=.PDF&FileName=Photo%2016%3A%20View%20of%20propeller.%20Courtesy%20of%20Continental.-Master.PDF - Photo 17: View of flight control sticks. Courtesy of Continental. (item 29, .PDF, 148 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200695&FileExtension=.PDF&FileName=Photo%2017%3A%20View%20of%20flight%20control%20sticks.%20Courtesy%20of%20Continental.-Master.PDF - Photo 18: View of fuel injector. Courtesy of Continental. (item 30, .PDF, 156 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200696&FileExtension=.PDF&FileName=Photo%2018%3A%20View%20of%20fuel%20injector.%20Courtesy%20of%20Continental.-Master.PDF - Photo 19: View of fuel pump. Courtesy of Continental. (item 31, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200698&FileExtension=.PDF&FileName=Photo%2019%3A%20View%20of%20fuel%20pump.%20Courtesy%20of%20Continental.-Master.PDF - Photo 20: View of magnetos. Courtesy of Continental. (item 32, .PDF, 174 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200700&FileExtension=.PDF&FileName=Photo%2020%3A%20View%20of%20magnetos.%20Courtesy%20of%20Continental.-Master.PDF - Photo 21: View of propeller governor. Courtesy of Continental. (item 33, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40200702&FileExtension=.PDF&FileName=Photo%2021%3A%20View%20of%20propeller%20governor.%20Courtesy%20of%20Continental.-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.