IAD98FA054

NTSB accident investigation · Beech A36 · Davis, WV · May 12, 1998

Accident · FatalField investigationFinal report
Date
May 12, 1998, 10:57 local (14:57 UTC)
Place
Davis, WV
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N72141Beech A36
Weather
Instrument (IMC) · Day
Status
Completed · report September 7, 2000
Report
Approved by Office Director
FAA report
19980512008939A
Case key
28252

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

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Probable cause

The pilot's spatial disorientation, his subsequent loss of control of the airplane, and his overload of the horizontal stabilizer during a recovery attempt. Factors include the pilot's continued flight into icing conditions, his lack of airspeed control, and the lack of an AIRMET advisory from the weather briefer.

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 flightCruise
Airframe - ice
Flight advisories - not advisedAtc personnel(fss)Factor
Remedial action - not performedPilot in commandFactor
Airspeed(vmo) - exceededPilot in commandFactor
Spatial disorientationPilot in commandCause
Aircraft control - not maintainedPilot in commandCause
Airframe/component/system failure/malfunctionDescent - uncontrolled
Horizontal stabilizer - overload
Design stress limits of aircraft - exceededPilot in commandCause

Analysis

The airplane was cruising on a southerly heading at 13,000 feet, in instrument meteorological conditions, when, over a 23-second period, it turned toward the west, descended about 1,200 feet, then broke up. The last 3-point smoothed ground speed calculation for the airplane indicated 242 knots. Winds aloft were from the east, about 10 knots. The airplane's maximum operating speed was 167 knots indicated, and maximum maneuvering speed was 141 knots indicated. At the time of the accident, the airplane was in conditions conducive to icing. The airframe anti-icing system was inoperative, and it was undetermined whether the engine and pitot ice protection systems had been activated. The horizontal stabilizer and the wings exhibited markings consistent with downward overstress separation. The flight originated from Hamilton, Ontario, and stopped at Buffalo, New York, before continuing. An AIRMET, calling for icing, was in effect, but not mentioned during the Ontario weather briefing. In Buffalo, no flight service station services were requested or provided. Flight into icing conditions in the accident airplane was prohibited, and the procedure was to turn back or change altitude to escape the icing.

Factual narrative

History of flight

On May 12, 1998, at 1057 Eastern Daylight Time, a turbine-powered Beech A36, N72141, was destroyed after an in-flight breakup during cruise flight near Davis, West Virginia. The certificated private pilot-owner and three passengers were fatally injured. Instrument meteorological conditions prevailed at the time, and an instrument flight rules flight plan had been filed for the flight from Buffalo Niagara International Airport (BUF), Buffalo, New York, to Moore County Airport (SOP), Southern Pines, North Carolina. The personal flight was conducted under 14 CFR Part 91.

The airplane had earlier departed Hamilton Airport (CYHM), Hamilton, Ontario, at 0730, and arrived in Buffalo at 0800, with only the pilot onboard. The pilot passed through U.S. Customs, then had the main fuel tanks topped off with 20 gallons of fuel. Afterwards, the pilot and passengers boarded the airplane, which departed Buffalo, at 0938. The airplane climbed to 13,000 feet, and proceeded southbound, toward its destination.

At 1054:04, after being advised to look out for traffic, the pilot stated, "I'm in the clouds." At 1055:43, the pilot acknowledged the altimeter setting. At 1058:43, the air traffic controller asked that the pilot recycle the airplane's transponder, but no answer was received.

The accident occurred during daylight hours, and the last secondary radar returns occurred at 39 degrees, 07.6 minutes north, 79 degrees 27.5 minutes west, less than 1/2 nautical mile east of where the main wreckage was located.

Personnel information

The last entry in the pilot's logbook, on April 3, 1998, indicated that the pilot had 1,478 hours of flight time. A maintenance record, dated April 29, 1998, listed the airplane's total flight hours at 2,233.9, while the tachometer reading at the accident site was estimated to be 2,239.6 hours.

On June 4, 1994, the pilot was unsuccessful in his attempt to pass a practical examination for his private pilot certification. On July 1, 1994, he completed a successful reexamination, and was issued his private pilot certification.

On February 25, 1995, the pilot was unsuccessful in his attempt to pass a practical examination for his instrument-airplane rating. On March 1, 1995, he completed a successful reexamination, and was issued his instrument-airplane rating.

The pilot attended formalized turbine-powered Bonanza training in the summer of 1996 at Flight Safety International. According to his flight instructor, the pilot related to him that en route to the training site, the pilot encountered a thunderstorm. This, in turn, resulted in hail damage to the airplane, and caused the airplane to lose about 6,000 feet of altitude. When the flight instructor asked what he did to get out of the situation, the pilot said that he tried to reverse course, but noticed he was in about a 60-degree bank, so he leveled the wings, put the landing gear down, reduced power, and "decided to plow through it."

The pilot also stated that upon arrival in the vicinity of the training site, he landed at the wrong airport, and ran off the runway and into the grass. He said he thought he was landing on Runway 36 at that airport, but landed on Runway 18 with a quartering tailwind of about 15 knots. The instructor confirmed the story about the landing with the airport's tower personnel. The instructor also confirmed the hail damage, which included some dings on the stainless steel wing leading edge de-ice system, and holes in the radome, some of which, the instructor could put his fingers through.

The pilot also told the instructor that one of the reasons he wanted to take the training is that he wanted to learn more about turbine engines. He had previously exceeded the engine temperature during a start, and had to have the hot section replaced.

According to an FAA accident/incident record, the pilot landed the accident airplane "with the landing gear in the up position" on August 10, 1996. The pilot had flown an instrument approach, then initiated a go-around and raised the landing gear. The pilot stated that on the second approach, he put the gear down, but the gear circuit breaker popped, failing to lower the gear. The pilot also stated that he did not notice the popped circuit breaker until the aircraft landed with the gear up. During a subsequent maintenance check, the landing gear operated "with no problems noted."

In a letter dated September 12, 1996, the FAA requested that the pilot take a competency re-examination, to "consist of Private/Instrument procedures with emphasis on rejected landings, missed approach procedures and emergency operations."

The pilot was unsuccessful in his attempts to pass reexaminations on November 12, 1996, November 20, 1996, and December 18, 1996.

In an FAA "Notice of Proposed Certificate Action" letter to the pilot, dated April 4, 1997, the following was stated in regards to the pilot's reexamination after the gear up landing:

"Subsequent to the...incident, you have attempted two (2) reexaminations. However, you have failed to successfully complete each of these two (2) reexaminations. By reason of the above, you lack the qualifications to be the holder of Private Pilot Certificate."

On September 11, 1997, the pilot successfully completed the reexamination.

According to an FAA Enforcement Investigative Report (EIR), on October 3, 1997, after making a night landing, the pilot taxied off the active runway, and realized he was on the grass, between the runway and the taxiway. The pilot then "turned the aircraft one hundred eighty degrees, and taxied back onto the active runway without a clearance or notifying the tower of his intentions." As a result, a Boeing 737 on short final had to go around.

The FAA requested reexamination of the pilot's competency, to be an "appropriate Private and Instrument practical test with emphasis on night flying in Turbo Prop Beech 36, ATC instructions and simulated emergency procedures."

On December 17, 1997, the pilot's reexamination attempt was unsatisfactory. The pilot was given a temporary certificate until January 20, 1998, and an extension which expired on February 20, 1998. In a March 10, 1998, letter to the pilot, an FAA Principal Operations Inspector noted that the pilot did not attempt to schedule a reexamination until called by another Inspector, on February 10, 1998. The letter also gave the pilot an additional 30 days from the date of the letter to complete the reexamination.

The pilot successfully completed his reexamination on April 2, 1998, and a temporary certificate was issued on that date.

Medical Information

On March 10, 1994, the manager of the FAA Aeromedical Certification Division, Civil Aeromedical Institute, wrote to the pilot that he was eligible for a third class medical certificate. However, it acknowledged the pilot's history of hypertension, and listed the requirements to maintain medical eligibility.

On an FAA Medical Certification System Medical Inquiry form which referred to the pilot, was written the following: "10/3/97 Totally lost - Failed several 609 rides. Need neuropsychological testing." It was dated November 24, 1997.

On November 25, 1997, a letter sent to the pilot from the manager of the Aeromedical Certification Division, stated that the FAA had received information which indicated a reasonable basis for a redetermination of the pilot's ability to meet medical standards prescribed in Part 67 of the Federal Aviation Regulations (FAR's). It also stated: "You may not be qualified to hold any class medical certificate."

The letter went on to request that the pilot "forward to this office current comprehensive neuropsychological testing."

The letter further stated:

"We would like to invite your attention to the provisions of FARs Section 61.53 and to caution you that in view of your possible disqualification, the e

Aircraft

Registration
N72141
Reported as
Beech A36
Category
Airplane
Serial number
E-2211
Airframe hours
2,240
Engine
Allison 250-B17F/2, 440 horsepower, turbo prop
Damage
Destroyed
Flight
Personal · Part 91
Operator
Howard L. Kidman
Registered owner
Maintland Valley Corp
Airworthiness certificate
Standard, Utility
Departed
BUF · Buffalo, NY
Destination
SOP · Pinehurst, NC
Flight plan
IFR

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
65
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
1,500 total · 365 in this make and model · 100 in the last 90 days · 50 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
1,600 ft broken
Temperature
57 °F, dew point 54 °F
Altimeter
29.00 inHg
Observed at
EKN, 25 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.