# NTSB SEA94FA055: Beech S35, N50VT, Ashland, OR, February 3, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 3, 1994, 12:45 local (20:45 UTC) - Place: Ashland, OR - Coordinates: 42.150314, -122.530944 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.1503&lon=-122.5309&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report December 2, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 41794 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA94FA055 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/41794/pdf - Page: https://openairdocs.org/ntsb/SEA94FA055 ## Probable cause POOR IN-FLIGHT PLANNING/DECISION. FACTORS TO THE ACCIDENT WERE: CLEARANCE WAS NOT MAINTAINED AND POOR SUPERVISION. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with object, maneuvering - object - tree(s) - clearance - not maintained, dual student (contributing factor) - in-flight planning/decision - poor, pilot in command(cfi) (cause) - supervision - poor, pilot in command(cfi) (contributing factor) ## Analysis WITNESSES OBSERVED THE AIRPLANE MAKING TWO LOW PASSES OVER OR NEAR THE AIRSTRIP BEFORE THE THIRD PASS WAS PERFORMED. DURING THIS THIRD PASS, THE AIRPLANE WAS MANEUVERING TO THE RIGHT SIDE OF THE AIRSTRIP. IT IS UNKNOWN IF THE PILOT INTENDED TO LAND. WITNESSES STATED THAT THE ENGINE SOUNDED NORMAL UP UNTIL JUST SECONDS BEFORE THE IMPACT WHEN THE ENGINE REVVED. DURING THE ENGINE INSEPCTION, NO EVIDENCE WAS FOUND TO INDICATE A MECHANICAL FAILURE OR MALFUNCTION. ## Factual narrative HISTORY OF FLIGHT On February 3, 1994, at 1245 Pacific standard time, a Beech S35, N50VT, collided with trees while maneuvering near the Pinehurst State Airstrip, Ashland, Oregon. Visual meteorological conditions prevailed at the time and no flight plan was filed. The airplane was destroyed by the post-crash fire and both the private pilot and flight instructor were fatally injured. The flight had originated from Medford, Oregon, on February 3, 1994, at 1230, for the local instructional flight. Witnesses reported that the airplane flew one low pass over the airstrip to the northeast, at approximately 80 feet above ground level. The airplane then flew another pass over the airstrip to the southwest. The airplane made a third pass to the southwest, at low level and slightly to the northwest side of the runway. The witnesses heard a loud revving sound from the engine just seconds before the impact with the trees. Prior to the revving sound, the witnesses reported that the sound of the engine was loud and smooth. Family members to the private pilot reported that the pilot had recently purchased the airplane. For insurance purposes, the pilot had to accumulate a total of 10 hours of flight time with a flight instructor on board. This flight was to complete the 10 hour requirement. PERSONNEL INFORMATION The flight logbooks for both pilots were reviewed. It was found that the flight instructor's logbook indicated that a total flight time of 2,586 hours had been accumulated. In the Beech S35, a total of 27 hours had been accumulated. The logbook indicates that the first flight, in the accident airplane, began on December 23, 1993. This flight was with the private pilot's son, who was also being checked out in the airplane. The private pilot's logbook indicates that a total flight time of 185 hours had been accumulated in all types of airplanes. A total of 99 hours were logged as pilot-in-command. The flights logged prior to December 26, 1993, were in low performance airplanes. On December 26, 1993, the pilot logged the first flight in the Beech S35 as dual instruction received. The last entry was logged on January 13, 1994, with an accumulated total time of seven hours of dual instruction received. There were no hours logged as pilot-in-command. The logbook did not indicate that the private pilot had been signed off for flight in a high performance airplane. WRECKAGE AND IMPACT INFORMATION The wreckage was located approximately 550 feet from the threshold of runway 4, and approximately 200 feet to the right of centerline. Trees paralleled the airstrip on both sides and an open field with short grass was directly off the end of runway 22. The surrounding trees measured in height from 30 feet to 75 feet. The wreckage was located at the edge of the trees northwest of the field. The airplane was laying inverted, with the nose of the airplane positioned on a magnetic bearing of 10 degrees. The terrain was level and covered with ground shrubs and dense trees. The wreckage distribution path was measured on a magnetic bearing of 190 degrees. Trees measuring in height of approximately 50 feet indicated evidence of impact damage. The first tree identified was broken 20 feet up from the base and the trunk measured 16 inches in diameter. Nine feet further, and 15 feet right of the measuring centerline, the limbs of another tree were broken off approximately 36 feet up from the base. A third tree with a 15 inch diameter trunk was broken ten feet up from the base. A pile of logs and tree limbs were laying cross the path that lead to the wreckage, approximately 44 feet from the third tree. The total wreckage distribution from the first tree to the middle of the main wreckage was 62 feet. The entire cockpit, fuselage and inboard main fuel tanks in the left and right wings had been consumed by fire. The empennage aft of the baggage compartment was intact. Both ruddervators remained attached at their respective hinges. Control continuity was established from the empennage to the forward cockpit area. Continuity was also established from both left and right ailerons to the forward cockpit area. The landing gear was retracted and the flaps were extended to 30 degrees. The left wing inboard section remained attached at the fuselage. The outboard section of the wing was broken near the flap and aileron junction. The outboard section was bent underneath the inboard section. The tip of the wing was just touching the side of the fuselage. The inboard section of the right wing had been completely consumed by the fire. The outboard section of the wing, near the tip, indicated a circular indentation along the leading edge of the wing. The aileron remained attached at the hinges, and the outboard section of the right flap remained attached at the outboard hinge. Fire and rescue personnel reported that before the wreckage was disturbed, it was noted that the throwover control yoke was positioned to the left side. The engine was in place to the fuselage and showed evidence of impact damage to the lower cowling and severe heat distress. The propeller remained attached at the crankshaft. One blade was bent slightly rearward. The propeller tip was curled forward along the trailing edge. The other blade was straight and displayed minor leading edge damage. During the engine inspection, it was noted that the accessories and associated housings were destroyed and melted by the fire. Initially the crankshaft would not rotate, however, further investigation revealed that aluminum from the housings had melted between the accessory gears preventing rotation of the crankshaft. All spark plugs displayed moderate electrode erosion and wear. Both magnetos were destroyed. Further teardown and inspection to the cylinders and associated assemblies, crankshaft, camshaft and govenor did not reveal evidence of a mechanical failure or malfunction. MEDICAL AND PATHOLOGICAL INFORMATION. The post mortem examination for both pilots was performed at Litwiller-Simonsen Funeral Home, Ashland, Oregon by James N. Olsen, M.D. The doctor reported that the cause of death to both pilots was from chemical asphyxiation due to carbon monoxide inhalation associated with the post impact fire. Toxicological samples for both pilots were sent to the Civil Aeromedical Institute in Oklahoma City, Oklahoma for examination. The test revealed elevated levels of Carboxyhemoglobin and Cyanide were detected in the blood for both pilots. SURVIVAL ASPECTS This airplane was equipped with a right side cabin door that swung outward and forward. The cabin middle windows could also have been used as an emergency exit by pulling the pin from the window operating mechanism and pushing out the window. Witnesses stated that smoke from the fire was seen almost immediately after the sound of the impact was heard. Search and rescue personnel reported that both occupants were found in the forward cockpit area. ADDITIONAL INFORMATION The wreckage was released to Specialty Aircraft, Redmond, Oregon, on February 17, 1994. ## Aircraft - Registration: [N50VT](https://openairdocs.org/deregistered/N50VT-2011-05-25), registration cancelled 2011-05-25, S/N D-7642, built 1964 (OpenAirDocs) - Reported make and model: BEECH S35 - Registry model: [Beech S35](https://openairdocs.org/model/beech-s35) (registry code 1151532) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-7642 - Airframe hours: 3370 - Engines: CONTINENTAL IO-520-B 285 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Operator: Madden, James C. - Registered owner: Madden, James C. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 1, 1993, 30 hours before - Departed: MFR, MEDFORD, OR - Airport: 24S, Pinehurst State, runway 22, 2,850 × 30 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; flight instructor, commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: right; toxicology performed; flight hours: 2,586 total, 27 in this make and model, 2,420 as pilot in command, 20 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 3 knots - Visibility: 30 statute miles - Lowest ceiling: none - Temperature: 46 °F, dew point 25 °F - Altimeter: 30.00 inHg - Observed at: MFR, 27 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 19940203001399A](https://openairdocs.org/incident/19940203001399A), Feb 3, 1994: Beech S35, Pinehurst, OR, Destroyed, 2 fatal. Made two low passes over airstrip. On third pass off side runway. Revved engine just prior impact. 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.