LAX99FA104

NTSB accident investigation · Beech 95-B55 · Coalinga, CA · February 19, 1999

Accident · FatalField investigationFinal report
Date
February 18, 1999, 17:45 local (Feb 19, 1999, 01:45 UTC)
Place
Coalinga, CA
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N125TWBeech 95-B55
Weather
Day
Status
Completed · report March 2, 2001
Report
Approved by Office Director
FAA report
19990218013629A
Case key
45820

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 inadvertant visual flight into instrument meteorological 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.

In flight encounter with weatherCruise
Weather condition - clouds
Light condition - daylight
Aircraft control - not maintainedPilot in commandCause
Vfr flight into imc - inadvertentPilot in commandCause
Loss of control - in flightDescent - uncontrolled

Analysis

The pilot and passenger had flown to northern California for dental work to be performed on the pilot. On the return trip they were receiving VFR advisories from ATC. They were maintaining VFR on top at 14,500 feet msl. A voice thought to be the passenger, who was a rated pilot, transmitted 'we're in big trouble up here' followed by other incomplete or unreadable transmissions. The airplane was lost from radar and radio contact. The wreckage was located in mountainous terrain. The airplane had collided with terrain while in a near vertical attitude. The pilot had obtained a preflight weather briefing prior to flight, and VFR was not recommended. A formal weather study indicated that the airplane most likely flew into clouds. Conditions were conducive for light to moderate rime icing in clouds at the airplane's flight altitude. The time was 11 minutes before official sunset in cloudy conditions.

Factual narrative

History of flight

On February 18, 1999, about 1745 hours Pacific standard time, a Beech 95-B55, N125TW, was destroyed in an in-flight collision with mountainous terrain near Coalinga, California. The private pilot and pilot rated passenger were fatally injured. The personal flight was being operated under 14 CFR Part 91 and no flight plan was filed. The nearest weather reporting facility is 33 miles to the east; however, local area residents reported instrument meteorological conditions with rain and wind existed near the accident site. The flight originated at Sacramento, California, at 1649 on the day of the accident and was destined for Fullerton, California.

The pilot and passenger had flown to northern California for dental work to be performed on the pilot. On the return trip they were receiving VFR advisories from ATC. They were maintaining VFR on top at 14,500 feet msl. A voice thought to be the pilot rated passenger transmitted "we're in big trouble up here" followed by incomplete and unreadable transmissions.

The aircraft was lost from radio and radar coverage at 14,500 feet msl, about 20 miles southeast of the Panoche VOR. Search efforts were initiated and the wreckage was subsequently found February 19 near Santa Rita Peak, in San Benito County.

The Federal Aviation Administration (FAA) coordinator made a request for radar data from NAS Lemoore. The tape was pulled, viewed, and then inadvertently erased following a breakdown in tape safeguarding procedures.

Prior to departure from the Sacramento Executive Airport, the pilot purchased 58.0 gallons of fuel and obtained a preflight weather briefing from the FAA Rancho Murrieta flight service station for the route of flight. According to the briefing VFR flight was not recommended.

Personnel information

At the private pilot's last third-class flight physical on February 26, 1998, he reported a total flight time of 2,500 hours. The pilot's logbook was not recovered.

Aircraft information

Examination of the airframe logbook revealed that an annual inspection had been performed on the aircraft February 14, 1999. At the inspection it was noted that the aircraft had accumulated 2,846.6 total flight hours. There were no time recording devices recovered from the wreckage.

Both engine logbooks revealed 179.4 hours had accumulated since major overhaul at the time of the last annual inspection. Copies of the logbook records are attached to this report.

According to a friend and hangar neighbor of the pilot, the Bendix FCS-810 autopilot had been inoperative for some time. They had removed components from his aircraft to see which of the components were not working, and were unsuccessful in finding the problem.

According to AlliedSignal, Ft. Lauderdale, Florida, an autopilot system component had been repaired at their facility December 7, 1998.

According to logbook information, the last 24-month ATC transponder test (FAR 91-413) and static/altimeter test (FAR 91-411) was performed on March 16, 1995.

Meteorological information

The nearest weather-reporting site is NAS Lemoore, about 33 miles east of the accident site. At 1755, they were reporting: wind 340 degrees at 11 knots; visibility 4 miles in haze; broken clouds at 10,000 feet; overcast at 12,000 feet; temperature 61 degrees Fahrenheit; dew point 52 degrees Fahrenheit; altimeter 30.06 inHg.

According to a Safety Board meteorology report, the visible satellite image for 1730 showed that the accident location was approximately on the northern edge of a west-southwest, east-northeast band of clouds. The visual appearance of the cloud elements in the line indicated that there might have been scattered convective elements in the line.

Infrared temperature data for 1730 and 1745 showed that cloud top temperatures decreased in vicinity of the accident area from -13 degrees to near -21 degrees Celsius. The Oakland and Vandenberg upper air soundings indicated that the height range between these temperatures were probably from a little above 15,000 feet to around 22,000 feet.

Airmets for turbulence and mountain obscuration were in effect for the area, with pilot reports of icing in the Fresno area.

According to a Safety Board sun and moon program the sun was 2 degrees above the horizon or 11 minutes from official sunset in cloudy conditions.

Wreckage and impact information

The Safety Board examined the wreckage on scene and after recovery. The accident site was located at 36 degrees 23.75 minutes north latitude by 120 degrees 38.01 minutes west longitude, about 3,500 feet msl.

The airplane wreckage was observed straddling a granite rock outcropping from a near vertical attitude as evidenced from wing and fuselage accordioning signatures. The wreckage was contained in a 50-foot circle with negligible scatter. There was no postcrash fire damage; there was evidence of fuel hydraulicing of the fuel cell areas.

The entire airplane was accounted for at the site. Control continuity was not possible due to the fragmented condition of the structure.

The propellers were severed from the engine crankshaft flanges with some tortional bluing observed at the fracture point. The propeller blades revealed leading edge damage, trailing edge "S" bending, and chordwise striations with loss of blade tips.

Medical and pathological information

On February 22, 1999, the San Benito County Sheriff/Coroner performed an autopsy on the pilot. During the procedure samples were obtained for toxicological analysis at the FAA Civil Aeromedical Institute in Oklahoma City, Oklahoma.

According to the report, the results were negative for carbon monoxide, cyanide, and drugs. The analysis was positive, all detected in the kidney, for ethanol (35 mg/dL, mg/hg), isobutanol (57 mg/dL, mg/hg), methanol (530 mg/dL, mg/hg), n-propanol (54 mg/dL, mg/hg), and acetaldehyde (4 mg/dL, mg/hg). Ethanol was also detected in the muscle at 10 mg/dL, mg/hg.

Additional information

Oxygen bottles and masks without mikes were found in the wreckage. It could not be determined whether oxygen was being used, or if the bottles had oxygen available.

The wreckage was released to the insurance company representative on April 21, 1999.

Aircraft

Registration
N125TW
Reported as
Beech 95-B55
Category
Airplane
Serial number
TC-1617
Airframe hours
2,846
Engine
Continental IO-470-L, 260 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Howard S. Goldman
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 14, 1999
Departed
SAC · Sacramento, CA
Destination
FUL · Fullerton, CA

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
62
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
2,500 total

Weather

Conditions
Day
Wind
340° at 11 knots
Visibility
4 statute miles
Lowest ceiling
10,000 ft broken
Temperature
61 °F, dew point 52 °F
Altimeter
30.00 inHg
Observed at
NLC, 34 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.