LAX08FA047

NTSB accident investigation · Beechcraft V35B · Selma, CA · January 18, 2008

Accident · FatalField investigationFinal report
Date
January 18, 2008, 14:00 local (22:00 UTC)
Place
Selma, CA
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Uncontrolled descent
Aircraft
N4662MBeechcraft V35B
Defining event
Uncontrolled descent: Aircraft structural failure
Weather
Visual (VMC) · Day
Status
Completed · report January 29, 2009
Report
Approved by Office Director
Parties
Hawker Beechcraft, Federal Aviation Administration
FAA report
20080118000339A
Case key
67409

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 failure to maintain control resulting in the in-flight break-up of the airplane due to aerodynamic overload. Contributing factors included the pilot's impairment due to multiple medical conditions and due to recent use of alcohol.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

AircraftAircraft › Aircraft structures · FailureBeech V35B: 2 casesAll aircraft: 72 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech V35B: 4 casesAll aircraft: 1,269 casesProbable cause
Impairment/incapacitation: alcoholPersonnel issues › Physical · PilotBeech V35B: 1 caseAll aircraft: 87 casesProbable cause
Oversight: oversight of personnelOrganizational issues › Support/oversight/monitoring · FAA/RegulatorBeech V35B: 1 caseAll aircraft: 26 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The airplane was on an IFR cross-country flight in clear VFR conditions. The radar track was consistent with the flight's ATC clearance to the south-southeast in a steady 900-foot-per-minute climb. About 4 minutes after departure the pilot requested to leave the frequency for 1 minute, which the controller approved. The airplane vanished from radar 4 minutes later and entered a 5,400-foot-per-minute or greater rate of descent. A witness saw the airplane "disintegrate" in flight. The airplane wreckage was distributed along a 1,541-foot-long north-south debris field in the vicinity of the last radar return. Examination of the wreckage did not reveal any evidence of a pre-existing airframe, engine, or flight control anomaly. The pilot had a history of episodic incapacitating pain, diabetes requiring insulin, the use of multiple potentially impairing medications, and a history of alcohol abuse. The pilot had not noted the pain, the diabetes, or the medications used to treat these conditions on his most recent application for airman medical certificate. The pilot's FAA medical records did note a history of driving while intoxicated in 1992, but the FAA had not requested any additional details surrounding the pilot's alcohol use. The pilot had been drinking alcohol within hours of the flight, and the forensic toxicology report was consistent with a blood alcohol level of approximately 0.07 percent at the time of the accident, sufficient to have resulted in impairment. The toxicology report also was consistent with the use of multiple prescription medications that are potentially impairing, but no blood was available for evaluation and it was therefore not possible to estimate when the medications might have been most recently used or whether the pilot may have been impaired by the medication use or by interactions between those medications and/or alcohol.

Factual narrative

History of flight

On January 18, 2008, approximately 1400 Pacific standard time, a Beechcraft V35B, N4662M, broke up in flight over a vineyard, 5.7 miles west of Selma, California. The airplane was operated by the owner under the provisions of Title 14 Code of Federal Regulations, Part 91. The commercial pilot was killed, and the airplane was destroyed. Visual meteorological conditions prevailed, and an instrument flight plan had been filed. The personal flight originated at Fresno Chandler Executive Airport, Fresno, California, around 1350.

A witness reported to the National Transportation Safety Board investigator-in-charge that he heard a loud screaming noise overhead. When he looked up he observed an airplane suddenly "disintegrate," and described the wings and fuselage floating to the ground. The wreckage was located in a vineyard, and was dispersed along a 1,541-foot distance in a north-south orientation.

Federal Aviation Administration (FAA) Air Traffic Controllers reported that the pilot requested a frequency change while climbing to his assigned altitude (9,000 feet msl), and when the airplane was around 7,000 feet (msl) radar contact with the airplane was lost. No other radio communications with the pilot were reported.

Radar data files from the Fresno Terminal Area Radar Control (TRACON) were obtained and the track associated with the transponder code of 3701 was plotted. The track begins at time 1352:18 off of Fresno Chandler Executive Airport in a northwest direction at a reported altitude of 500 feet. The track proceeds to turn from a northwest direction to a southeast (approximately 110-degree heading). About 1353, at 3,100 feet, the track turns south. About 1356, at 4,700 feet, the track turns to the south-southeast. At this point the pilot requests the frequency change from Fresno TRACON. The track continues on the south-southeast heading while climbing at 900 feet per minute. At 1359:29, the track achieves its maximum altitude of 8,000 feet. The subsequent radar return, at 1359:39, indicates an altitude of 7,100 feet. This last radar return was in the vicinity of the airplane debris field. The rate of descent associated with the last radar return is 5,400 feet per minute.

Personnel information

The pilot, age 78, held commercial pilot certificates for airplane single engine, multiengine, and instrument, issued February 23, 1993. A third-class medical certificate was issued on April 19, 2007, with no restrictions. One page of the pilot's logbook was recovered from the airplane debris field. That page documented a biennial flight review dated April 29, 2006. The rest of the pilot's logbook was not located. On the pilot's April 19, 2007, medical certificate application he reported 4,500 civilian flight hours. On his April 24, 1991, medical certificate application he reported 3,500 military flight hours, and 4,100 civilian flight hours. In subsequent medical certificate applications the pilot reported having 8,000 plus flight hours.

A review of the pilot's FAA medical records revealed that he had an excessive blood alcohol level conviction on June 19, 1992, in the state of California, and failed to report it to the FAA (FAR 61.15e). The pilot surrendered his pilot certificate on November 27, 1992, and the FAA suspended his certificate for 20 days.

A relative of the pilot stated that the pilot was traveling to San Diego for a business meeting. The relative indicated the pilot had met a friend for lunch before departing and that he normally would have one vodka on the rocks at lunch. He was a social drinker.

Aircraft information

The four seat, low wing, retractable landing gear airplane, serial number D-10125, was manufactured in 1978. It was powered by a Teledyne Continental Motors IO-520-BA14, 285 horsepower engine, and equipped with a Hartzell three bladed constant speed propeller. Review of the airframe maintenance logbook showed a 100-hour inspection was performed on March 14, 2007, at a total airframe time of 2,931 hours. The engine maintenance logbook documented that an engine teardown and propeller strike inspection was performed on August 25, 2006, at a total time of 527.63 hours, and engine tach time of 2893.63. A 100-hour inspection was performed on March 14, 2007, at an engine tach time of 2,931 hours, and the time since over haul (TSOH) was 38 hours.

Meteorological information

Fresno Chandler Executive Municipal Airport weather observation for 1353 on January 18, 2008, was winds from 290 degrees at 3 knots; 5 statute miles visibility in haze; sky was clear; temperature was 13 degrees C; dew point was 1 degree C; and the altimeter setting was 30.20 inHg.

Communications

At 1347, the pilot received his IFR clearance from Fresno approach. The pilot was cleared to Montgomery San Diego, via the Chandler published departure, vectors to Lake Hughes, then as filed. Initial climb altitude was 9,000 feet, and his radar identification squawk was 3701. At 1351, the pilot reported airborne and was given the vector of 110 degrees to fly. At 1353, he was directed to proceed direct to Lake Hughes. At 1356, the pilot requested to "...go back to alternate frequency for one minute." The controller approved the frequency change and instructed the pilot to report when he was back on frequency. At 1400, the controllers tried unsuccessfully to contact the pilot. The controllers noticed that they had lost the airplane's radar return and squawk signal from their scopes. No further transmissions were received from the pilot or airplane.

Wreckage and impact

The debris field was located in a vineyard, on level terrain, and ran in a north-south direction for 1,500 feet. The wreckage was fragmented into the following main component groups; engine and cockpit instrument panel, left wing, right wing, and fuselage. The empennage and ruddervators fragments were dispersed with in the debris field.

The right wing spar exhibited downward bending and a matte gray granular fracture surface. The right wing retained its flaps and aileron. The left wing spar remained bolted to the wing carry through spar; its flap and aileron were separated from the wing, along with a 6- by 2-foot middle wing skin section. All separated control cable displayed broomstrawed ends. The empennage-tail section was fragmented into 13 pieces. The left ruddervator spar was fractured at the ruddervator root; the fracture surface was matte gray and uniform in appearance with 45-degree shear lips. The right ruddervator was attached to the 256 bulkhead, which had separated from the empennage. Both elevators were separated from the stabilizer in pieces; both balance weights were located in the debris field.

The main fuselage, minus the engine, tail, and wings, was in a single piece. The forward right seat and rear passenger seats were attached to the fuselage. The left seat (pilots) was located about 3 feet away and detached from the fuselage. The control yoke, pedals, and instrument panel were not attached to the front section of the fuselage. The seat belts were not deformed or cut; the belt buckles exhibited no evidence of distress.

The engine, propeller, instrument panel, control yoke, and rudder pedals were located together. The instrument panel and firewall had wrapped itself around the accessory section of the engine. The propeller was detached from the engine but was found in line with the engine crank shaft. The control yoke arm and connecting structure was fragmented.

The pilot was located at the south end of the debris field separate from other pieces of wreckage.

Medical and pathological information

An autopsy was performed on the pilot on January 19, 2008, by the Fresno County Coroner, Fresno. The autopsy report noted the cause of death to be "multiple skeletal and visceral injuries due to airplane crash." The autopsy report noted that many of the organs were abse

Aircraft

Registration
N4662M
Reported as
Beechcraft V35B
Category
Airplane
Serial number
D-10125
Airframe hours
2,931
Engine
Teledyne Continental IO-520-BA14, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Robert G. Mollring
Registered owner
Robert G. Mollring
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
100 hour · March 1, 2007
Departed
KFHC · Fresno Chandler, CA
Destination
KMYF · San Diego, CA
Flight plan
IFR
Airport
KFCH · Fresno Chandler Executive

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
78
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
April 1, 2006
Seat
Left
Toxicology
Performed
Flight hours
8,000 total

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 3 knots
Visibility
5 statute miles
Lowest ceiling
None
Temperature
55 °F, dew point 34 °F
Altimeter
30.20 inHg
Observed at
KFAT, 13 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.