# NTSB NYC04FA036: Beech J35, N748CH, Somerset, KY, November 20, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 20, 2003, 08:30 local (13:30 UTC) - Place: Somerset, KY - Coordinates: 37.062778, -84.611946 - Nearby events: https://openairdocs.org/map.md?lat=37.0628&lon=-84.6119&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report September 29, 2004 - Report: Approved by Office Director - Parties: FAA FSDO-01, Continental Motors, Raytheon Aircraft - NTSB case key (mKey): 58365 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC04FA036 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58365/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=58365 - Page: https://openairdocs.org/ntsb/NYC04FA036 ## Probable cause A total loss of engine power during takeoff for undetermined reasons. A factor was the impairment of the pilot in command due to an over-the-counter antihistamine. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, takeoff - initial climb - reason for occurrence undetermined (cause) - Forced landing, descent - emergency - In flight collision with object, descent - emergency - object - tree(s) - impairment(drugs), pilot in command (contributing factor) ## Analysis During takeoff and initial climb, the engine "missed" six times. The airplane entered a left turn toward the airport, but the engine lost all power. The airplane subsequently struck trees and impacted a field about 1/2 mile north of the airport. Examination of the wreckage revealed that the fuel selector was positioned between "LH TANK" and "OFF;" however, the pre-impact position of the fuel selector could not be verified. Review of the airplane maintenance records revealed that after several reports of engine power losses during landing rolls, the fuel system was replaced about 5 months prior to the accident. A fuel leak was discovered and corrected shortly after the replacement. Following the correction, the airplane flew approximately 14 hours during the 5-month period, with no known discrepancies regarding the engine. After the accident, several components on the engine were replaced or repaired due to impact damage, and a successful test run of the engine was completed. Toxicological testing for the pilot in command revealed the presence of doxylamine, a sedating over-the-counter antihistamine commonly found in multi-symptom cold relievers such as NyQuil, and sleep aids such as Unisom. The level of doxylamine was consistent with ingestion of the maximum single over-the-counter dose of a sleep aid within a few hours prior to the accident. Post-accident interviews with the pilot's wife revealed that he was suffering from common cold symptoms such as coughing and congestion. The pilot was treating the cold with NyQuil at night, and non-drowsy Sudafed during the day. ## Factual narrative HISTORY OF FLIGHT On November 20, 2003, about 0830 eastern standard time, a Beech J35, N748CH, was substantially damaged during a forced landing, following a loss of engine power after takeoff from Somerset-Pulaski County Airport (SME), Somerset, Kentucky. The certificated flight instructor, pilot-rated passenger, and a second passenger were fatally injured. Visual meteorological conditions prevailed for the planned flight to Blue Grass Airport (LEX), Lexington, Kentucky. An instrument flight rules flight plan was filed for the commercial flight conducted under 14 CFR Part 91. A pilot, standing on the ramp at SME, witnessed the accident. He stated that during the takeoff on runway 04, about the time of rotation, the engine began "missing." The engine "missed" about six times as the airplane climbed to approximately 400 feet above the ground. During the initial climb, the landing gear retracted. The airplane then began a left turn back toward the airport, the landing gear began to extend, and the engine lost all power. The airplane subsequently descended, struck trees, and impacted terrain about 1/2-mile north of the airport. The accident occurred during the hours of daylight; located about 37 degrees, 03.77 minutes north latitude, and 84 degrees, 36.72 minutes west longitude. PERSONNEL INFORMATION The pilot in command held a commercial pilot certificate, with ratings for airplane single engine land, airplane multi-engine land, and instrument airplane. He also held a flight instructor certificate, with a rating for airplane single engine land. The pilot in command's most recent Federal Aviation Administration (FAA) second class medical certificate was issued on November 1, 2002. According to his logbook, the pilot in command had accumulated approximately 1,542 hours of total flight experience. He had accumulated approximately 91 hours of flight time during the 90 days preceding the accident; of which, about 3 hours were in the accident airplane. The pilot rated passenger held a private pilot certificate, with ratings for airplane single engine land, and instrument airplane. His most recent FAA first class medical certificate was issued on March 12, 2003. The pilot rated passenger had accumulated approximately 250 hours of total flight experience. AIRCRAFT INFORMATION The airplane's most recent annual inspection was performed on June 24, 2003. At that time, the complete engine fuel system was removed, overhauled, and reinstalled. According to the tachometer, the airplane had accumulated approximately 14 hours of operation since the last annual inspection was completed. According to a pilot who previously flew the accident airplane, he had experienced several engine problems in the past. Specifically, while he was a passenger in 2001, the engine lost all power during a landing roll. In 2002, while piloting the airplane, the engine lost all power during two separate landing rolls. The pilot further stated that during the first flight after the fuel system was replaced, a fuel leak was located and corrected. However, there were no subsequent problems with the engine or airframe following the replacement of the fuel system and correction of the leakage. METEOROLOGICAL INFORMATION The reported weather at SME, at 0856, was: wind calm; visibility 10 miles; sky clear; temperature 44 degrees F; dew point 37 degrees F; altimeter 30.13 inches Hg. AERODROME INFORMATION SME was serviced by runway 04/22. The runway was 5,400 feet long, 100 feet wide, and consisted of asphalt. According to the witness pilot, the accident site was located in a field beyond the departure end of runway 4. The witness further stated that local pilots often referred to that field as an option for an emergency landing. WRECKAGE AND IMPACT INFORMATION The wreckage was examined at the accident site on November 21, 2003. A debris path originated at a damaged tree, and extended about 160 feet on an approximate 240-degree magnetic heading. Ground scars were observed about 120 feet along the debris path. Propeller blades and portions of the right wing navigation light were found in the vicinity of the ground scars. The wreckage was situated at the end of the debris field. It was inverted and oriented about a 290-degree magnetic heading. All major components of the airplane were accounted for at the scene. According to witnesses, a strong odor of fuel was present after the crash, and fuel was observed leaking from the right wing. The right wing main fuel tank was compromised, and the left wing main fuel tank contained fuel consistent with 100LL aviation gasoline. Some fuel was also observed in both auxiliary fuel tanks. The selector valve fuel sump was absent of fuel and contamination. The flush vents for the left and right main fuel tanks contained some debris. The empennage was partially separated and canted right. The right and left outboard wing sections were partially separated and folded upward. Both wings exhibited impact damage at the leading edge, but the damage to the right wing was more severe. Flight control continuity was confirmed from all control surfaces to the cockpit area. The flaps were observed in the retracted position, and the ailerons were found in an approximate neutral position. The landing gear was found in the extended position. Measurement of the elevator trim tab jackscrew corresponded to an approximate neutral trim setting. The cockpit was equipped with a "T-bar" dual control configuration. The fuel selector was found between the "LH TANK" and "OFF" positions. The throttle and propeller levers were found about 1/2-inch from the full forward position, and the mixture lever was found in the lean position. The magneto switch was selected to "BOTH," and the auxiliary fuel pump was found "OFF." The cockpit area was crushed, and none of the seats were equipped with shoulder harnesses. One propeller blade exhibited slight "s-bending," and the other propeller blade exhibited slight chordwise scratching. The engine remained partially attached to the airframe, and was retained for further examination. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilots by the Commonwealth of Kentucky, Office of the Chief Medical Examiner, Louisville, Kentucky. Toxicological testing was conducted on the pilots at the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma. The toxicological report for the pilot in command revealed: "0.12 (ug/ml, ug/g) DOXYLAMINE detected in Blood DOXYLAMINE present in Urine EPHEDRINE detected in Blood EPHEDRINE detected in Urine PHENYLPROPANOLAMINE detected in Blood PSEUDOEPHEDRINE detected in Blood PSEUDOEPHEDRINE detected in Urine DIPHENHYDRAMINE present in Urine DIPHENHYDRAMINE NOT detected in Blood" The pilot in command's wife stated that he was suffering from common cold symptoms such as coughing and congestion. He was treating the cold with NyQuil at night, and non-drowsy Sudafed during the day. TESTS AND RESEARCH On February 5, 2004, the engine was test run at the manufacturer's facility, under the supervision of an FAA inspector. Due to impact damage, the following parts were repaired or substituted for operation: All fuel control fittings Engine mounts Ignition harness Induction system pipe Induction system risers - Number 1, 2, 3, and 5 cylinder positions Induction system throttle body - The fuel control attach bosses required weld repair to allow attachment of the fuel control unit Induction system balance tube Fuel control fuel return port fitting cap Number 1 cylinder exhaust push-rod housing Number 4 cylinder fuel injection line Number 5 cylinder intake push-rod housing and push-rod Number 5 cylinder rocker cover Remote oil cooler adapter plate Spark plugs Starter adapter Starter In addition, the magnetos were re-timed du ## Aircraft - Registration: [N748CH](https://openairdocs.org/deregistered/N748CH-2009-04-10), registration cancelled 2009-04-10, S/N D5600 (OpenAirDocs) - Reported make and model: Beech J35 - Registry model: [Beech J35](https://openairdocs.org/model/beech-j35) (registry code 1151522) (OpenAirDocs) - Category: Airplane - Serial number: D5600 - Airframe hours: 3860 - Engines: Continental IO-470 250 horsepower reciprocating - Damage: Substantial damage - Flight: Other work use, Part 91 - Operator: Mock Air - Registered owner: Ronald Centers - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 24, 2003, 14 hours before - Departed: SME, Somerset, KY - Destination: LEX, Lexington, KY - Flight plan: IFR - Airport: SME, Somerset-Pulaski County, runway 4, 5,400 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; injuries: fatal; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; last flight review February 26, 2003; seat: left; toxicology performed; flight hours: 1,545 total, 1,445 as pilot in command, 91 in the last 90 days, 69 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 45 °F, dew point 37 °F - Altimeter: 30.12 inHg - Observed at: SME, 1 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 20031120037879A](https://openairdocs.org/incident/20031120037879A), Nov 20, 2003: Beech J35, Somerset, KY, Substantial damage, 3 fatal. (-23) Aircraft departed sme enroute to lex KY. Flight plan filed but not opened. Upon departure witness stated engine began sputtering and lost power. Aircraft… ## Docket (14 files) The files NTSB released with the investigation on August 23, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=58365. 7.3 MB in all. - Interview Summaries (item 1, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409466&FileExtension=.PDF&FileName=Interview%20Summaries-Redacted.PDF - Witness Statements (item 2, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40215377&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Excerpts from Pilot Logbooks (item 3, .PDF, 704 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409467&FileExtension=.PDF&FileName=Excerpts%20from%20Pilot%20Logbooks-Redacted.PDF - TCM Engine Operational Test Report (item 4, .PDF, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409469&FileExtension=.PDF&FileName=TCM%20Engine%20Operational%20Test%20Report-Redacted.PDF - Maintenance Records (item 5, .PDF, 452 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409470&FileExtension=.PDF&FileName=Maintenance%20Records-Redacted.PDF - Weather Report (item 6, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40215384&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - Fueling Records (item 7, .PDF, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40215386&FileExtension=.PDF&FileName=Fueling%20Records-Master.PDF - Toxicological Reports (item 8, .PDF, 158 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409471&FileExtension=.PDF&FileName=Toxicological%20Reports-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 9, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409473&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409474&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1 - Accident Site (item 11, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40215398&FileExtension=.PDF&FileName=Photo%201%20-%20Accident%20Site-Master.PDF - Photo 2 - Wreckage (item 12, .PDF, 472 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40215400&FileExtension=.PDF&FileName=Photo%202%20-%20Wreckage-Master.PDF - Photo 3 - Fuel Selector (item 13, .PDF, 482 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40215402&FileExtension=.PDF&FileName=Photo%203%20-%20Fuel%20Selector-Master.PDF - Photo 4 - Fuel Screen (item 14, .PDF, 416 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40215403&FileExtension=.PDF&FileName=Photo%204%20-%20Fuel%20Screen-Master.PDF 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.