# NTSB NYC01FA172: Beech A23-24, N5962S, Bridgeville, DE, July 15, 2001 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 15, 2001, 18:26 local (22:26 UTC) - Place: Bridgeville, DE - Coordinates: 38.740028, -75.600669 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.7400&lon=-75.6007&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report June 18, 2002 - Report: Approved by Office Director - Parties: FAA FSDO-17, Raytheon Aircraft, Lycoming Engines - NTSB case key (mKey): 52703 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC01FA172 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/52703/pdf - Page: https://openairdocs.org/ntsb/NYC01FA172 ## Probable cause The pilot's incapacitation, which resulted in a loss of aircraft control while maneuvering. A factor was the FAA Aeromedical Certification Division's inadequate certification/approval of the pilot's medical certificate. Findings were the pilot's inappropriate use of medication, and depression. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, maneuvering - inadequate certification/approval,airman, faa(organization) (contributing factor) - incapacitation, pilot in command (cause) - aircraft control - not maintained, pilot in command - depression, pilot in command - use of inappropriate medication/drug, pilot in command - In flight collision with terrain/water, descent - uncontrolled - terrain condition - crop ## Analysis The pilot, an orthopedic surgeon, departed his home airport and flew over the local area for about 1 hour. The airplane was observed circling over a cornfield, and initially climbed, but then descended rapidly into the terrain. Witnesses stated that the engine noise could be heard, and was consistent throughout the accident. Examination of the wreckage did not reveal any pre-impact mechanical malfunctions. Review of the pilot's medical and pharmacy records revealed a history of Hodgkin's disease, substantial damage to his gastrointestinal tract, hypothyroidism, gall bladder disease, and coronary artery bypass surgery. In addition, the pilot required most of his calories to be delivered intravenously through a surgically placed port in his chest. Within 1 year prior to the accident, the pilot had filled prescriptions for Synthroid, Zoloft, Deseryl, Prozac, Imodium, and Lasix. The pilot wrote all of his most recent prescriptions. However, on his most recent application for an FAA third class medical certificate, the pilot listed only Synthroid as a currently used medication. An aviation medical examiner noted the pilot's weight at 152 pounds, and his height at 71 inches. The examiner did not issue a medical certificate, and deferred it to the FAA Aeromedical Certification Division, citing the Hodgkin's disease, coronary artery disease, bowel adhesions, and "a central line which he still uses for occasional enteral feeding." The Manager of the FAA Aeromedical Certification Division authorized a special issuance of a third class medical certificate, but did not mention the abdominal problems, the presence of a central line, or the need for parenteral feeding. The Manager did note a history of coronary artery disease. Toxicological testing performed on the pilot revealed sertraline and tramadol present in the blood. The level of sertraline present in the blood was more than five times higher than would be expected from maximum recommended dosage. The level of tramadol in the blood was almost twenty times the maximum level expected from a typical single dose of the drug. Sertraline (Zoloft) is a prescription antidepressant, and tramadol is a prescription narcotic-like painkiller. ## Factual narrative HISTORY OF FLIGHT On July 15, 2001, about 1826 eastern daylight time, a Beech A23-24, N5962S, was substantially damaged while maneuvering near Bridgeville, Delaware. The certificated private pilot was fatally injured. Visual meteorological conditions prevailed for the flight that departed Sugar Hill Airport (DE17), Greenwood, Delaware. No flight plan was filed for the local personal flight conducted under 14 CFR Part 91. According to witnesses, the pilot departed DE17, about 1715. He flew over Rehoboth Bay about 1800, and was circling in the vicinity of the accident site, about 1820. One witness stated that the airplane initially climbed, then descended rapidly into a cornfield. The witness added that she heard a consistent engine noise. Another witness stated that the airplane circled his house twice, and he thought the airplane was "a crop-duster setting up for a low pass." The witness heard the engine noise continuously, followed by the sound of the impact. The accident occurred during the hours of daylight; located approximately 38 degrees, 45.39 minutes north latitude; and 75 degrees, 32.22 minutes west longitude. PERSONNEL INFORMATION The pilot was an orthopedic surgeon. He held a private pilot certificate, with ratings for single engine land and instrument airplane. Although the pilot's logbook was not recovered, he reported a total flight experience of 1,030 hours on his most recent application for a Federal Aviation Administration (FAA) third class medical certificate. AIRCRAFT INFORMATION The airplane's last annual inspection was performed on May 20, 2001. At that time, the airplane had accumulated approximately 2,138 hours of operation. At the time of the accident, the airplane had accumulated approximately 2,142 hours of operation. METEOROLOGICAL INFORMATION The reported weather at an airport approximately 10 miles away, at 1854 was: wind from 320 degrees at 6 knots; visibility 10 miles; clear sky; temperature 80 degrees Fahrenheit, dew point 55 degrees; altimeter 29.97 inches Hg. WRECKAGE AND IMPACT INFORMATION The wreckage was examined at the accident site on July 16, 2001. It was located in a cornfield, about 55 feet above sea level. At the beginning of the debris path, the corn stalks were observed cut at an approximate 45-degree angle. The pilot tube and red navigation light were found near the beginning of the debris path. The path extended about 16 feet from the origin, on a heading about 130 degrees, to the main impact crater. The path then extended about 105 feet, on a heading about 100 degrees, to the main wreckage. Along the 105-foot debris path, the propeller, rudder, nose gear, and right aileron were found. All major components of the airplane were accounted for at the scene. The main wreckage was oriented about a northerly heading. Both wings were folded aft of the fuselage, and both fuel tanks were ruptured. Flight control continuity was confirmed from all control surfaces on the empennage to the cockpit control column. Continuity was also confirmed from the right aileron bellcrank to the cabin area. One of the left aileron bellcrank arms was observed fractured, consistent with overload, and its respective aileron cable (forward) was not recovered. However, control continuity of the 2nd left wing aileron cable (aft) was confirmed from the bellcrank to the cabin area. The left wing exhibited impact damage along the leading edge, and was buckled. The left flap was broken and deflected downward. The left aileron was separated from the wing. The right wing also exhibited impact damage along the leading edge, and was severely crushed. The right flap was broken and deflected downward. The right aileron was separated from the wing. The empennage was twisted, and resting on top of the fuselage. The horizontal stabilator was intact, the vertical stabilizer had separated from the aft fuselage, and the rudder was found separated from the stabilizer. The elevator trim actuator measurement was beyond the full nose down trim position, which was consistent with trim system being subjected to impact forces. The fuselage was crushed, and the emergency locator transmitter was damaged during the impact. The cockpit was destroyed, and the pilot's seat had been ejected. However, a few readings were secured from the cockpit. The magneto switch was selected to "BOTH", and the throttle and mixture controls were found in the full forward position. The manual flap control corresponded to a flaps retracted setting. The propeller had separated from the crankshaft, and was located about 18 feet beyond the main impact crater. Both propeller blades exhibited s-bending and gouges on both the leading and trailing edges. One blade was curled near the tip. The top spark plugs and valve covers were removed from the engine for inspection. The spark plugs appeared gray in color, and their electrodes were intact and absent of debris. Where the propeller had separated, the crankshaft was bent consistent with impact damage. In an attempt to rotate the crankshaft, the forward top and bottom through-bolts were loosened. The crankshaft was then rotated by hand using an accessory gear drive in the rear of the engine, with the assistance of a strap that was wrapped around the forward section of the crankshaft. Crankshaft and camshaft continuity were confirmed. Valve train continuity was confirmed, and thumb compression was attained on all cylinders. Both magnetos suffered impact damage, and did not produce spark when rotated by hand. However, when the left magneto was rotated by hand, the impulse coupling engaged. The right magneto cover was removed for inspection. When the right magneto was rotated by hand, all points opened. The injector was inspected, and the throttle valve was found open. Approximately 1/2 ounce of fuel was recovered from the engine driven fuel pump and the fuel injector. The fuel was light blue in color, and consistent in smell to aviation gasoline. The oil filter was inspected, and was found absent of debris. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by the Office of the Chief Medical Examiner, Wilmington, Delaware. The autopsy report stated that the cause of death was "multiple severe traumatic injuries due to plane crash." The report also noted "transection of the great vessels (aorta, pulmonary artery, venae cavae, and pulmonary veins)." Noted pre-existing disease included: Cardiovascular System: "fibrous pericarditis," "focal fibrosis of myocardium," "myocardial infarction, healed, of posterior left ventricle," and "arteriosclerotic coronary artery disease with coronary artery bypass drafts x 2" Respiratory System: "fibrous pleuritis, bilateral" Gastrointestinal System: "obliteration of the peritoneal cavity by dense fibrous adhesions," "sub-total gastrectomy, healed," and "sub-total colectomy, healed" Liver and Gall Bladder: "chronic cholecystitis and cholelithiasis" Genitourinary System: "Atherosclerotic nephrosclerosis, early" The pilot's most recent Federal Aviation Administration (FAA) medical examination was performed on April 23, 2001. In a letter dated May 9, 2001, the FAA Manager of the Aeromedical Certification Division authorized a special issuance for a third class medical certificate, valid until April 30, 2002. According to the NTSB Medical Officer's factual report, the pilot listed only Synthroid as any currently used medication on his application for an FAA third class medical certificate. He also indicated "yes" for "Heart or vascular trouble," "Stomach liver, or intestinal trouble," "Military medical discharge," and "Admission to hospital." The pilot indicated "no" for "Mental disorders of any sort; depression, anxiety, etc." The pilot's aviation medical examiner noted the pilot's height at 71 inches and weight at 152 lbs. T ## Aircraft - Registration: [N5962S](https://openairdocs.org/deregistered/N5962S-2002-01-11), registration cancelled 2002-01-11, S/N MA-46, built 1966 (OpenAirDocs) - Reported make and model: Beech A23-24 - Registry model: [Beech A23-24](https://openairdocs.org/model/beech-a23-24) (registry code 1151226) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: MA-46 - Airframe hours: 2142 - Engines: Lycoming IO-360 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Donald M. Pfeifer - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 20, 2001, 4 hours before - Departed: DE17, Greenwood, DE - Airport: DE17, Sugar Hill Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 1,030 total ## Weather - Conditions: Visual (VMC), Day - Wind: 320° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 55 °F - Altimeter: 29.96 inHg - Observed at: GED, 10 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 (OpenAirDocs). - [Accident 20010715022299A](https://openairdocs.org/incident/20010715022299A), Jul 15, 2001: Beech A2324, Bridgetown, DE, No damage. (-23) Pilot crashed in a corn field approximately 3 NM east of Bridgetown, DE. ## Other investigations on N5962S (1) 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. - [NTSB NYC67D0522](https://openairdocs.org/ntsb/NYC67D0522), Mar 11, 1967: Beech A23 (N5962S), Oneonta, NY, substantial damage 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.