# NTSB NYC06FA079: Beech 56TC, N18LL, Winfield, WV, March 18, 2006 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 17, 2006, 22:37 local (Mar 18, 2006, 03:37 UTC) - Place: Winfield, WV - Coordinates: 38.513332, -81.898887 - Nearby events: https://openairdocs.org/map.md?lat=38.5133&lon=-81.8989&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report May 29, 2007 - Report: Approved by Office Director - Parties: FAA/FSDO, Raytheon Aircraft Company, Textron Lycoming - NTSB case key (mKey): 63358 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC06FA079 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/63358/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=63358 - Page: https://openairdocs.org/ntsb/NYC06FA079 ## Probable cause The pilot's inadequate preflight preparation to ensure an adequate supply of supplemental oxygen, and his inadequate in-flight planning and decision making, which resulted in exhaustion of his oxygen supply, and incapacitation from hypoxia during cruise flight. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Miscellaneous/other, cruise - preflight planning/preparation - inadequate, pilot in command (cause) - in-flight planning/decision - inadequate, pilot in command (cause) - oxygen system - exhaustion (cause) - incapacitation(anoxia/hypoxia), pilot in command - Loss of engine power(total) - nonmechanical, cruise - fluid,fuel - exhaustion - In flight collision with terrain/water, descent - uncontrolled - terrain condition - mountainous/hilly ## Analysis While on the last leg of a multiple day cross-country trip, all communications between the pilot of a non-pressurized, oxygen system equipped airplane, and air traffic control (ATC) were normal until the airplane was detected to have climbed 400 feet above its assigned altitude of FL240. After being notified of the deviation, the pilot responded that he was attempting to look at his contrails. Later in the flight, after leveling at FL270, the pilot queried ATC as to whether they had heard some of his previous calls. This was the last transmission received from the pilot, and attempts to reestablish contact were unsuccessful. After the pilot had not begun his descent for landing, nor joined the arrival course for his destination, ATC requested assistance from the North American Aerospace Defense Command (NORAD). After intercepting the airplane, the pilots of the fighter airplanes attempted to look into the cockpit, but were unable to see the pilot. Attempts to gain his attention were also unsuccessful. The airplane eventually descended and impacted terrain. A nasal cannula was connected to the airplane's installed oxygen system and was found near the pilot. An oxygen mask the pilot was wearing was connected to a portable oxygen bottle found on the floor next to him. Both systems were functional, their valves were open, and both were depleted of their contents. The portable bottle was manufactured for industrial use, and modified with an oxygen system fitting. The regulator was manufactured for the medical industry. A review of a journal kept by the pilot revealed that he flew at high altitudes for efficiency, and used an oximeter to monitor blood oxygen. He used a nasal cannula at altitudes exceeding 18,000 feet for comfort, and had used a "cannula and mask" up to 31,000 feet. Examination of his hangar revealed an aircraft oxygen tank and welding tank plumbed to an oxygen-service fitting. The airplane's oxygen system or portable bottle had not been serviced at the airports the airplane operated from during the trip. According to Advisory Circular (AC) 61-107A, "Operations of Aircraft At Altitudes Above 25,000 Feet MSL And/Or Mach Numbers (MMO) Greater Than .75", preflight inspections should include a thorough examination of aircraft oxygen equipment, "including available supply," and that "Oxygen systems should be checked periodically to ensure that there is an adequate supply of oxygen and that the system is functioning properly. This check should be performed frequently with increasing altitude. If supplemental oxygen is not available, an emergency descent to an altitude below 10,000 feet should be initiated." Additionally, it advised that when using continuous flow oxygen systems above 25,000 feet, "very careful attention to system capabilities is required." ## Factual narrative HISTORY OF FLIGHT On March 17, 2006, at 2237 eastern standard time, a Beech 56TC, N18LL, was substantially damaged when it impacted terrain in Winfield, West Virginia. The certificated private pilot was fatally injured. Night visual meteorological conditions prevailed for the flight that departed Dawson Community Airport (GDV), Glendive, Montana, destined for St. Paul Downtown Airport (STP), St. Paul, Minnesota. An instrument flight rules flight plan was filed for the personal flight conducted under 14 CFR Part 91. All times listed in this report are eastern standard time. The accident occurred on the last leg of a multiple day cross-country trip. During the multiple day trip, the pilot operated the airplane at cruise altitudes up to 27,000 feet. Earlier on the day of the accident, the pilot flew uneventfully from Havre City Airport (HVR), Havre, Montana to GDV. The airplane was fueled before departing HVR, and again after arriving at GDV. The pilot then departed on the accident flight at 1843, for STP. According to communications and radar data, all communications were normal until the pilot was advised by air traffic control (ATC) that he was 400 feet higher than assigned. In response he stated, "Lima Lima roger, I was just trying to look behind me and it's the first time I've ever noticed that I'm making contrails." After receiving climb clearance from Salt Lake Air Route Traffic Control Center (ARTCC) the flight was handed off to the Minneapolis ARTCC. The pilot reported on Minneapolis Center frequency at 1858, leaving FL240 for FL270. The airplane leveled at FL270 at 1903. At 1937, the pilot queried ATC if they heard his previous transmissions stating, "Did you hear me call in a few times?" This was the last transmission received from the pilot. Multiple attempts to make contact with the pilot were unsuccessful, and at 1952, ATC realized that radio contact had been lost. At 2011, they began to prepare for the airplane to begin its descent for landing at STP; however, at 2027, the airplane had not started to descend, nor join the arrival course. Instead, it continued on a southeasterly heading. At 2040, the airplane overflew St. Paul and assistance was requested from the North American Aerospace Defense Command (NORAD). At 2049, fighter airplanes "scrambled" to intercept the accident airplane. At 2055, two airliners flying over the airplane attempted to look into the cockpit, but were unsuccessful. At 2106, the pilots of the intercepting fighter airplanes acquired the accident airplane on radar, with visual acquisition occurring at 2114. After closing with the airplane, they observed that the airplane's position lights, strobes, and rotating beacon were illuminated, and the interior lights appeared to be at a "dim setting." They also attempted to look into the cockpit, but were unable to visually observe the pilot. Multiple attempts to gain the pilot's attention by firing flares and doing an afterburner flyby were unsuccessful. At 2146, two more fighter aircraft were "scrambled" by NORAD to relieve the original intercepting flight, which was running low on fuel. The replacement fighters began tracking the airplane at 2204, and also attempted to gain the pilot's attention by firing flares. These pilots also noted in the darkness, that the airplane's interior lights were on, but could not see the pilot or discern any movement. About 2234, the airplane began to descend, and at 2237, ATC lost radar contact with the airplane. Witnesses who lived adjacent to the accident site reported that about 2250 they heard a "boom," similar to "a bomb exploding," outside of their residence. After stepping outside, they observed two fighter airplanes pass overhead. A short time later, an emergency medical service helicopter circled their house, landed, and then departed. At approximately 2319 they discovered the wreckage of the airplane on a hill behind their residence. The accident occurred during the hours of darkness. The wreckage was located at 38 degrees, 30.792 minutes north latitude, 81 degrees, 53.933 minutes west longitude. PERSONNEL INFORMATION The pilot held a private pilot certificate, with ratings for airplane single and multi engine land, and instrument airplane. His most recent FAA third class medical certificate was issued on September 15, 2004. According to his pilot logbooks, he had accrued 2,469 total hours of flight experience, and 757 hours in the accident airplane make and model. AIRCRAFT INFORMATION The aircraft was a twin-engine turbo-charged, six-place non-pressurized airplane manufactured in 1968. It came equipped from the factory with an onboard oxygen system. The airplane's most recent annual inspection was completed on March 27, 2005, and at that time had accumulated 2,670.9 total hours of operation. METEOROLOGICAL INFORMATION A weather observation taken about 17 minutes after the accident at Yeager Airport (CRW), Charleston, West Virginia, located about 10 nautical miles southeast of the accident site, recorded the winds as 300 degrees at 8 knots, visibility 10 miles, sky clear, temperature 39 degrees Fahrenheit, dew point 19 degrees Fahrenheit, and an altimeter setting of 30.24 inches of mercury. WRECKAGE AND IMPACT INFORMATION The main wreckage came to rest at an elevation of 590 feet, perpendicular to a 20-degree downslope. It was oriented on a heading of 360 degrees magnetic. The entire wreckage was contained in a single area approximately 3 feet aft of the point of impact. No ground scarring, except for three indentations, 12 to 14 inches deep, corresponding to the positions of the propellers and nose of the airplane, were noted. Varying degrees of impact damage were present. Compression damage and an associated crush line were visible on the right outer wing panel, and were measured at a 20-degree angle, perpendicular to the chordline. The aft fuselage section exhibited compression damage aft of the cabin on the left side, and was displaced approximately 2 degrees to the left of the cabin area. Examination of the airplane and engines revealed no evidence of preimpact malfunction, and examination of the combustion heater revealed no evidence of leakage. MEDICAL AND PATHOLOGICAL INFORMATION A postmortem examination was performed on the pilot by the State of West Virginia's Office of the Chief Medical Examiner. Toxicological testing of the pilot was conducted at the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. TESTS AND RESEARCH The pilot, who was bearded, was found strapped into the left front seat of the airplane wearing an oxygen mask. A pulse oximeter was discovered laying on the ground 6 feet outboard of the left wingtip. In addition to the installed oxygen system on the airplane, a portable oxygen system was found during the wreckage examination. A nasal cannula was connected to the airplane's oxygen system and found on the seat next to the pilot. The mask the pilot was wearing was connected to the portable oxygen system, which was found next to the pilot, on the floor of the cabin. The regulator valves of both systems were open approximately halfway, and both were depleted. Oxygen Equipment Testing of the airplane's installed and portable oxygen systems revealed that all of their components were functional. According to the Baron 56TC Owner's Manual, the installed oxygen system consisted of a 114-cubic foot capacity cylinder located in the nose baggage compartment. The system had six outlets. The regulator was an altitude compensating type, which limited system operation to altitudes above 8,000 feet. Above this altitude a sensing element would increase oxygen flow to each occupant from 50 psi to 70 psi as altitude increased. When use of the oxygen was discontinued, it was "absolutely necessary" that the system be turned "OFF" by closing the contr ## Aircraft - Registration: [N18LL](https://openairdocs.org/deregistered/N18LL-2006-07-11), registration cancelled 2006-07-11, S/N TG-65, built 1968 (OpenAirDocs) - Reported make and model: Beech 56TC - Registry model: [Beech 56TC](https://openairdocs.org/model/beech-56tc) (registry code 1152736) (OpenAirDocs) - Registry engine: [Lycoming TI0-541 series](https://openairdocs.org/engine/lycoming-ti0-541-series) (registry code 41536, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TG-65 - Airframe hours: 2766.7 - Engines: Lycoming TIO-541-E1B4 380 horsepower reciprocating; Lycoming TIO-541-E1B4 380 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 1, 2005, 87.4 hours before - Departed: GDV, Glendive, MT - Destination: STP, St. Paul, MN - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review September 1, 2005; seat: left; toxicology performed; flight hours: 2,469 total, 757 in this make and model, 2,383 as pilot in command, 26 in the last 90 days, 16 in the last 30 days, 9 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night - Wind: 300° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 39 °F, dew point 19 °F - Altimeter: 30.23 inHg - Observed at: CRW, 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 20060317011729A](https://openairdocs.org/incident/20060317011729A), Mar 17, 2006: Beech 56TC, Winfield, VA, Destroyed, 1 fatal. (-23) An IFR flight plan was filed for the personal flight from kgdv to kstp. According to preliminary communication and radar data all communications were… ## Docket (27 files) The files NTSB released with the investigation on April 16, 2007, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=63358. 11.0 MB in all. - On Scene Examination of N18LL (item 1, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273422&FileExtension=.PDF&FileName=On%20Scene%20Examination%20of%20N18LL-Master.PDF - On Scene Witness Statements and Interview Summaries (item 2, .PDF, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273423&FileExtension=.PDF&FileName=On%20Scene%20Witness%20Statements%20and%20Interview%20Summaries-Redacted.PDF - Ground Track and Flight History (N18LL) (item 3, .PDF, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274736&FileExtension=.PDF&FileName=Ground%20Track%20and%20Flight%20History%20(N18LL)-Master.PDF - Partial Transcript of Radio Communications (N18LL and Interception Activity) (item 4, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273426&FileExtension=.PDF&FileName=Partial%20Transcript%20of%20Radio%20Communications%20(N18LL%20and%20Interception%20Activity)-Redacted.PDF - United States Air Force Intercept report (item 5, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273429&FileExtension=.PDF&FileName=United%20States%20Air%20Force%20Intercept%20report-Redacted.PDF - Excerpts From Pilot's Journal (item 6, .PDF, 308 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273570&FileExtension=.PDF&FileName=Excerpts%20From%20Pilot%27s%20Journal-Redacted.PDF - Excerpt From Pilot's Logbook (item 7, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273571&FileExtension=.PDF&FileName=Excerpt%20From%20Pilot%27s%20Logbook-Master.PDF - Beechcraft Oxygen System Servicing Instructions (item 8, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273572&FileExtension=.PDF&FileName=Beechcraft%20Oxygen%20System%20Servicing%20Instructions-Master.PDF - Beechcraft Oxygen System Description and Duration Charts (item 9, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273573&FileExtension=.PDF&FileName=Beechcraft%20Oxygen%20System%20Description%20and%20Duration%20Charts-Master.PDF - Excerpt of Checklist in Owners Manual (Oxygen System) (item 10, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273574&FileExtension=.PDF&FileName=Excerpt%20of%20Checklist%20in%20Owners%20Manual%20(Oxygen%20System)-Master.PDF - Excerpts From Checklists Found In Wreckage (Oxygen System) (item 11, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273575&FileExtension=.PDF&FileName=Excerpts%20From%20Checklists%20Found%20In%20Wreckage%20(Oxygen%20System)-Master.PDF - Engineering Sketches and System Description of Hammon Regulator Valve as provided by the United States Patent Office (item 12, .PDF, 299 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273576&FileExtension=.PDF&FileName=Engineering%20Sketches%20and%20System%20Description%20of%20Hammon%20Regulator%20Valve%20as%20provided%20by%20the%20United%20States%20Patent%20Office-Redacted.PDF - Systems Description of Nelson A-4 Flow Meter (item 13, .PDF, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273577&FileExtension=.PDF&FileName=Systems%20Description%20of%20Nelson%20A-4%20Flow%20Meter-Master.PDF - Aerox Electret Microphone Mask Instruction Information (As Found in Wreckage and As Provided by Manufacturer) (item 14, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273578&FileExtension=.PDF&FileName=Aerox%20Electret%20Microphone%20Mask%20Instruction%20Information%20(As%20Found%20in%20Wreckage%20and%20As%20Provided%20by%20Manufacturer)-Redacted.PDF - Portable Bottle Examination (item 15, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273580&FileExtension=.PDF&FileName=Portable%20Bottle%20Examination-Redacted.PDF - Hammon Regulator and Nelson A-4 Flow Meter Examination (Portable Oxygen) (item 16, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273581&FileExtension=.PDF&FileName=Hammon%20Regulator%20and%20Nelson%20A-4%20Flow%20Meter%20Examination%20(Portable%20Oxygen)-Redacted.PDF - Pulse Oximeter Information (Manufacturers Information) (item 17, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273583&FileExtension=.PDF&FileName=Pulse%20Oximeter%20Information%20(Manufacturers%20Information)-Master.PDF - N18LL Oxygen Servicing Survey (Departure and Destination Airports) (item 18, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273585&FileExtension=.PDF&FileName=N18LL%20Oxygen%20Servicing%20Survey%20(Departure%20and%20Destination%20Airports)-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 19, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273587&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 20, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273588&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Pilot's Toxicological Report (item 21, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273584&FileExtension=.PDF&FileName=Pilot%27s%20Toxicological%20Report-Redacted.PDF - Photograph 1 Main Wreckage (Front View) (item 22, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273589&FileExtension=.PDF&FileName=Photograph%201%20Main%20Wreckage%20(Front%20View)-Master.PDF - Photograph 2 Installed and Portable Oxygen Bottles (item 23, .PDF, 693 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273590&FileExtension=.PDF&FileName=Photograph%202%20Installed%20and%20Portable%20Oxygen%20Bottles-Master.PDF - Photograph 3 Hammon Regulator (item 24, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273591&FileExtension=.PDF&FileName=Photograph%203%20Hammon%20Regulator-Master.PDF - Photograph 4 Flowmeter (During Test) (item 25, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273592&FileExtension=.PDF&FileName=Photograph%204%20Flowmeter%20(During%20Test)-Master.PDF - Photograph 5 Oximeter (item 26, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273593&FileExtension=.PDF&FileName=Photograph%205%20Oximeter-Master.PDF - Photograph 6 Pilot's Oxygen Servicing System (Located in Hangar at KSTP) (item 27, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40273938&FileExtension=.PDF&FileName=Photograph%206%20Pilot%27s%20Oxygen%20Servicing%20System%20(Located%20in%20Hangar%20at%20KSTP)-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.