LAX02FA210

NTSB accident investigation · Beech C35 · Chambers, AZ · June 30, 2002

Accident · FatalField investigationFinal report
Date
June 29, 2002, 21:24 local (Jun 30, 2002, 04:24 UTC)
Place
Chambers, AZ
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N5856CBeech C35
Weather
Visual (VMC) · Night
Status
Completed · report September 13, 2005
Report
Approved by Office Director
Parties
Federal Aviation Administration, Raytheon Aircraft Company
FAA report
20020629024459A
Case key
55081

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 pilot's loss of airplane control after falling asleep due to fatigue, which resulted in a structural failure of the airframe during a high speed descent after the design stress limits of the aircraft were exceeded.

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
FatiguePilot in commandCause
Aircraft control - not maintainedPilot in commandCause
Light condition - night
Airframe/component/system failure/malfunctionDescent - uncontrolled
Design stress limits of aircraft - exceededPilot in command
Miscellaneous,airframe - separation
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

During a nighttime cross-country flight in clear visual meteorological conditions, the airplane departed from controlled flight and broke up during a steep high speed descent. Wreckage was located over a 1,650-foot-long southerly path about 0.4 miles from the last recorded radar position, with the right wing and right stabalator found early in the debris field. The pilot had awakened at 0600 and reported for work at 0750, and he had flown five contract flights dispersing fire retardant chemical on wildfires for a total of 7.4 flight hours on the day of the accident. Upon completing his last flight about 1900, the pilot was overheard stating "we had a tough one today." He then laid his head down on the airplane's wing and said, "dang I'm tired." A second associate reported that the pilot had experienced difficulty completing the required end of day paperwork, making arithmetic errors during simple addition calculations. This associate thought the pilot was tired and "mentally exhausted." The pilot told this associate that he was going to spend the night in a local hotel, but instead he departed about 2022. The pilot requested and received VFR radar flight following service, and at no time did the pilot indicate he was experiencing any difficulties or request assistance. Following about an hour of cruise flight at 10,500 feet, during the last 19 seconds of radar-recorded flight, the airplane's average ground track changed from 241 degrees to 170 degrees, while its altitude increased from 10,900 to 11,000 feet. There were no further altitude readouts. The airplane broke apart in flight and impacted flat, desert terrain at an altitude of about 6,200 feet mean sea level. The right wing spar fractures were positive overload failures and evidence shows that it separated and impacted the right stabilizer, which also then separated.

Factual narrative

History of flight

On June 29, 2002, about 2124 mountain standard time, a Beech C35, N5856C, experienced an uncontrolled descent and in-flight breakup following a departure from cruise flight. The accident occurred about 20 nautical miles (nm) south-southeast (153 degrees, magnetic) of Chambers, Arizona. The airplane impacted desert terrain and was destroyed. The commercial pilot, the sole occupant, was fatally injured. Visual meteorological conditions prevailed in the vicinity, and no flight plan had been filed. The nighttime personal flight was performed under the provisions of 14 CFR Part 91. The flight originated from near Albuquerque, New Mexico, approximately 1 hour earlier, at an estimated time of 2022.

According to the Federal Aviation Administration's (FAA) quality assurance staff at the Albuquerque Air Route Traffic Control Center (ARTCC), the pilot had requested, and was receiving, visual flight rules (VFR) radar flight following service for his flight to Buckeye, Arizona. The airplane was initially radar identified about 9 nm southwest of the Double Eagle II (uncontrolled) Airport, near Albuquerque. At the time, the airplane was climbing through 8,400 feet. The pilot informed the radar controller that he intended to climb to 10,500 feet. The radar track indicated that the airplane proceeded in a westerly direction while climbing between 10,900 and 11,000 feet, as indicated by the airplane's altitude reporting (Mode C) transponder. At no time during the flight did the pilot indicate he was experiencing any difficulties or request assistance.

The last communication with the accident airplane occurred at 2031. At this time, the Albuquerque ARTCC controller issued the pilot the Albuquerque altimeter setting, which was 30.04 inches of mercury (inHg). The pilot acknowledged the information.

The airplane's average ground speed from 2045:12 to 2121:12 was about 134 knots. During the last 19 seconds of radar recorded flight (between 2123:08 and 2123:27), the airplane's average ground track changed from a west-southwesterly (241 degrees) to a southerly direction (170 degrees), while its altitude increased from 10,900 to 11,000 feet. There were no further altitude readouts from the airplane's transponder on any of the following four final radar hits, which were at 2123:36, 2123:46, 2123:56, and 2124:05.

The main wreckage was found about 0.4 nm south of the airplane's last known position (LKP). No witnesses reported having observed the airplane's descent and/or ground impact.

Personnel information

The pilot held a commercial pilot certificate with an airplane single engine land rating. He was not instrument rated. The pilot also held an airframe and powerplant mechanic certificate. The pilot's total flight time and flying experience in the accident model of airplane was about 12,581 and 192 hours, respectively.

When the pilot was not performing agricultural pilot operations for an Arizona-based company, he was employed as a contract pilot and flew for the United States Forest Service (USFS) and the Bureau of Indian Affairs (BIA).

USFS personnel reported to the National Transportation Safety Board investigator that on the accident day the pilot had reported for work about 0750, and he performed his first flight about 1100. By the end of the day, the pilot had flown on five contract flights dispersing fire retardant chemicals on wildfires for a total of 7.4 flight hours.

At the end of the workday, the pilot informed a BIA associate that he intended to spend the night in a local New Mexico hotel rather than flying home to Arizona. He planned to fly home the following morning.

The BIA associate reported to the Safety Board investigator that the pilot had experienced difficulty completing the required end of day paperwork. The pilot was observed making arithmetic errors regarding calculating his flight and duty times for the day's work. The associate subsequently reported to the Safety Board investigator that he thought the pilot was tired and was "mentally exhausted."

Upon completing his last firefighting contract flight the pilot was overheard stating to another associate "we had a tough one today." He then laid his head down on the airplane's wing and said something like "dang I'm tired." Thereafter, the pilot departed on the accident flight.

Aircraft information

The airplane's maximum never exceed speed was 177 knots indicated airspeed (KIAS). Its maneuvering speed was 114 KIAS.

The airplane was maintained on an annual inspection basis. It was not equipped with an autopilot.

Meteorological information

National Oceanic and Atmospheric Administration radar summary and weather depiction charts, along with surface observation data for the accident site vicinity indicated that the sky was generally clear. High pressure prevailed in the region and there were no reported radar echoes.

Five aviation weather reporting facilities were located between 22 and 72 nm, circumferentially around the accident site. A review of the reported surface weather at these facilities from approximately 30 minutes before to 30 minutes after the time of the accident revealed a clear sky condition, with surface wind at or less than 10 knots. The barometric pressure varied from 30.08 to 30.24 inches of mercury.

The closest aviation weather reporting facility to the accident site was St. Johns, Arizona (SJU). At 2054, SJU reported the following weather: Wind from 260 degrees at 9 knots; visibility 7 miles; sky clear; temperature/dew point 26/00 degrees Celsius, respectively; and altimeter 30.13 inches of mercury.

Aids to navigation

The FAA reported that all electronic aids to navigation pertinent to, and in the vicinity of, the accident site were operating normally.

Communication

Albuquerque ARTCC's quality assurance staff reported that all services for the airplane had been normal.

Wreckage and impact information

The accident site is located at the following global positioning satellite (GPS) coordinates: 34 degrees 52.4 minutes north latitude by 109 degrees 19.7 minutes west longitude. Wreckage fragments and structural components from the airplane's wings, tail, and all the flight control surfaces were located in the accident site area. The main wreckage was found on flat, desert terrain, at an approximate elevation of 6,200 feet mean sea level (msl).

Components from the fragmented right wing and fragmented right ruddervator/stabilizer were located near the northern end of an approximate 1,650-foot-long wreckage distribution path. The main wreckage, consisting of the fuselage and its attached left wing, and the engine, were located near the southern portion of the distribution path. The principal axis of the wreckage distribution path was about 195 degrees, magnetic. The specific locations where 19 components were found were documented using a GPS receiver. (See the wreckage distribution diagram for their locations.) There was no evidence of fire.

Medical and pathological information

On July 2, 2002, the Pima County Office of the Medical Examiner, Forensic Science Center, 2825 East District, Tucson, Arizona, performed an autopsy on the pilot. The autopsy was performed at the request of the Apache County Sheriff's Office, in whose jurisdiction the accident occurred. In addition, toxicological specimens of blood and urine were analyzed by the University Medical Center, Tucson. No evidence of ethanol or drugs was found.

The FAA's Toxicology and Accident Research Laboratory, Oklahoma City, Oklahoma, also analyzed toxicological specimens of blood and urine. No evidence of ethanol or drugs was found.

Family members and acquaintances of the pilot reported that he had been in excellent health. No drug usage history was acknowledged.

Tests and research

Duty Time Requirements.

According to the USFS's regional safety manager,

Aircraft

Registration
N5856C
Reported as
Beech C35
Category
Airplane
Serial number
D-2808
Airframe hours
4,429
Engine
Continental E-185-11, 205 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
William C. Wood
Registered owner
David Kerr
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 20, 2002 · 8 hours before
Departed
AEG · Albuquerque, NM
Destination
10AZ · Buckeye, AZ

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
47
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land
Medical
Class 2, Valid Medical--no waivers/lim.
Last flight review
March 1, 2002
Seat
Left
Toxicology
Performed
Flight hours
12,581 total · 192 in this make and model · 8 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
260° at 9 knots
Visibility
7 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 32 °F
Altimeter
30.12 inHg
Observed at
SJN, 22 nm away

Docket · 34

The files NTSB released with the investigation on July 12, 2005, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.1 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 307 KBStatements, WitnessesItem 2 · .PDF · 37 KBStatements, FAA PersonnelItem 3 · .PDF · 200 KBWreckage DiagramItem 4 · .PDF · 40 KBRadar Track and MapsItem 5 · .PDF · 191 KBWeather ReportsItem 6 · .PDF · 980 KBTranscriptsItem 7 · .PDF · 67 KBPhoto 1 - Empennage in TreeItem 8 · .PDF · 84 KBPhoto 2 - Main WreckageItem 9 · .PDF · 115 KBPhoto 3 - Leading Edge Right Wing in FieldItem 10 · .PDF · 78 KBPhoto 4 - Engine in FieldItem 11 · .PDF · 79 KBPhoto 5 - Engine and Propeller BladeItem 12 · .PDF · 72 KBPhoto 6 - Airplane (Front View)Item 13 · .PDF · 105 KBPhoto 7 - Empennage Left SideItem 14 · .PDF · 673 KBPhoto 8 - Right Wing (Reconstuction)Item 15 · .PDF · 843 KBPhoto 9 - Left WingItem 16 · .PDF · 673 KBPhoto 10 - Left Wing Rear ViewItem 17 · .PDF · 646 KBPhoto 11 - Top of Right Wing with contact rivet marks A2 & B2Item 18 · .PDF · 261 KBPhoto 12 - Bottom of Right Stabilizer showing contact marks A1 & B1Item 19 · .PDF · 233 KBReport of Aircraft AccidentItem 20 · .PDF · 61 KBParty Report - BeechItem 21 · .PDF · 141 KBAircraft and Engine LogsItem 22 · .PDF · 401 KBRadar Data, N56CNT2.TXT NTAPItem 23 · .PDF · 203 KBRadar Data, N56CNTP7.TXT NTAPItem 24 · .PDF · 121 KBRadar Data, N56CNTP6.TXT NTAPItem 25 · .PDF · 165 KBRadar Data, N56CNTP5.TXT NTAPItem 26 · .PDF · 164 KBRadar Data, N56CNTP4.TXT NTAPItem 27 · .PDF · 191 KBRadar Data, N56CNTP3.TXT NTAPItem 28 · .PDF · 178 KBRadar Data, N56CNTP2.TXT NTAPItem 29 · .PDF · 146 KBRadar Data, N56CNTP.TXT NTAPItem 30 · .PDF · 118 KBToxicological Report - FAAItem 31 · .PDF · 48 KBToxicological Report - University Medical CenterItem 32 · .PDF · 152 KBStatement of Party Representatives to NTSB InvestigationItem 33 · .PDF · 240 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 34 · .PDF · 49 KB

FAA reports on this event · 1

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

Other investigations on N5856C · 1

Matched to the same aircraft by N-number and date.