# NTSB WPR09FA235: Beech 95, N1533Z, Minden, NV, May 9, 2009 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: May 9, 2009, 16:10 local (23:10 UTC) - Place: Minden, NV - Coordinates: 38.929164, -119.818336 - Nearby events: https://openairdocs.org/map.md?lat=38.9292&lon=-119.8183&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 5 fatal - Status: Completed, report April 22, 2010 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration, Teledyne Continental Motors - NTSB case key (mKey): 73800 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09FA235 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73800/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73800 - Page: https://openairdocs.org/ntsb/WPR09FA235 ## Probable cause The pilot's failure to maintain an adequate airspeed while maneuvering during a low altitude maneuver that resulted in a stall. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech 95-A55, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=1152704), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech 95-A55, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1152704), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech 95-A55, 7 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1152704), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Abrupt maneuver](https://openairdocs.org/ntsb-events/270); cases with it: [Beech 95-A55, 1 case](https://openairdocs.org/ntsb-events/270/sequence.md?model=1152704), [All aircraft, 346 cases](https://openairdocs.org/ntsb-events/270/sequence.md) - [Maneuvering-low-alt flying: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Beech 95-A55, 2 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=1152704), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Maneuvering-low-alt flying: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech 95-A55, 6 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1152704), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis Witnesses reported that the pilot had taken four friends that were attending an outdoor working group on a local flight. The airplane made two to three low passes over the working group. On the final pass, the airplane was slightly above the tops of the local houses, between 100 and 300 feet above ground level (agl). Recovered GPS data indicated that the airplane was traveling from northeast to southwest at 120 knots ground speed. The witnesses stated that the airplane then made a sudden steep climbing left turn that approached 90 degrees angle of bank, appeared to decelerate at the top of the climbing turn, then dropped towards the ground nose first to ground impact. The witnesses noted that the engines could be heard "running perfectly" throughout the maneuver. Post accident examination of the airplane established continuity from all control surfaces to the cockpit. Examination of both engines revealed no abnormal conditions or signatures. ## Factual narrative HISTORY OF FLIGHT On May 9, 2009, at 1610 Pacific daylight time, a Beech BE-95-A55, N1533Z, impacted terrain while maneuvering at low altitude near Minden, Nevada. The airplane was operated by the private pilot under the provisions of Title 14 Code of Federal Regulations Part 91. The pilot and four passengers were killed, and the airplane was substantially damaged. Visual meteorological conditions prevailed, and a visual flight plan had not been filed. The flight originated at Minden-Tahoe Airport, Minden, about 1600. Witnesses reported to the Douglass County Sheriff that the pilot had taken four friends that were attending an outdoor working group on a local flight. The airplane made two to three passes over the working group. On the final pass, witnesses reported that the plane was slightly above the tops of the local houses, between 100 and 300 feet above ground level (agl), traveling from northeast to southwest. The airplane made a sudden steep climbing left turn, appeared to decelerate at the top of the climbing turn, then dropped towards the ground nose first, and impacted the grass field. Witnesses consistently reported that the airplane appeared to be in 90 degrees angle of bank just before it descended. The engines could be heard "running perfectly" throughout the maneuver. A hiker in the hills to the west of the accident site photographed the airplane just before the accident. The photographer was above the airplane and the photograph depicts the airplane flying over the grass pasture with the landing gear and flaps retracted. The airplane casts a shadow on the ground directly below it. The distance between the airplane and shadow appears to be between 2 to 4 wingspans. The photograph is located in the official docket of this investigation report. A Garmin 295 handheld global positioning system (GPS) unit was recovered from the airplane. The GPS was sent to the Safety Board Vehicle Recorders Laboratory for data recovery. The data recovered was disjointed, and the recorded altitudes are below ground elevation. The flight track appears to start in mid flight, near the accident location, and makes a rough figure eight pattern before abruptly ending over the accident location. The final leg of the GPS track proceeds from northeast to southwest at approximately 120 knots ground speed. The GPS track plot is contained in the official docket of this investigation report. PERSONNEL INFORMATION The pilot, age 58, held a private pilot certificate, with ratings for airplane single-engine land, airplane single-engine sea, airplane multiengine land (visual flight rules (VFR) only), and instrument airplane, issued on May 30, 1996. He held a third-class airman medical certificate issued on December 12, 2008, with the limitation that he must use corrective lenses for near and distant vision. Examination of the pilot’s logbook revealed an incomplete record of his flying activities; two entries for 2005, one entry for 2006, and one entry for 2008. Hismost recent flight review was dated April 28, 2008. A friend of the pilot, who is also a pilot, stated that the accident pilot was known to make irregular entries in his logbook, and used it only to record required flights such as a check ride. According to this witness, the pilot operated an aircraft sales company out of the Minden Airport and flew almost every day. On the pilot’s December 12, 2008, application for his medical certificate he indicated that he had 4,700 hours of total flight hours, and had accumulated 90 hours within the previous 6 months. The pilot also held a mechanic certificate with ratings for airframe and powerplant, with inspection authorization (IA) issued on May 3, 1994. His IA was dated March 2009. AIRCRAFT INFORMATION The five-place, low wing, twin engine airplane, serial number (S/N) TC-326, was manufactured in 1962. It was powered by two Teledyne Continental Motors IO-470-L 260-horsepower engines, and equipped with McCauley two-bladed constant speed propellers. The airplane maintenance records were not located and were not examined by investigators. The airplane's weight and balance documentation was not located. Utilizing the stall speed chart located in the Pilot’s Operating Handbook for the Beechcraft BE-95-A55, a stall speed for 60 degrees angle of bank was estimated for the airplane at max gross weight, 4,880 pounds. With the flaps up, power idle, the stall speed at 60 degrees angle of bank is approximately 105 knots. WRECKAGE AND IMPACT The wreckage was located in an open grass field, consisting of moist soft earth and mud. The surrounding area consisted of rural farm houses and barn structures. The airplane wreckage was confined to the immediate crash location. No ground scars leading up to the wreckage were identified. The nose of the airplane and both engines were embedded into the ground about 2.5 feet. The tail section and fuselage were present and elevated slightly above the ground. All control surfaces (elevator, rudder, ailerons, trim tabs) and flaps were present on their hinges. Both wings exhibited leading edge crushing. The occupiable space in the cabin had been collapsed to about half the normal space by the bottom fuselage of the airplane being crushed up in to the bottom of the instrument panel. The nose of the airplane was crushed up and aft. First responders had peeled back the cabin roof to access the victims. First responders reported fuel odor and leakage into the ground. The wreckage was oriented from tail to nose on a bearing of 342 degrees magnetic. Control continuity was established by tracing the control cables from the tail and ailerons to the cockpit area. All cables were found to pass through the appropriate guides and attached to the appropriate bell cranks or control chain ends. The left flap actuator was measured extended 3.5 inches, the right flap actuator was measured extended 4.0 inches, which corresponds to approximately a 10-degree flap setting. Engine control cables weretrapped within the wreckage structure but were traced from the engines to the cockpit. All engine control cables were attached to the engines’ throttle body or propeller governor. The left and right fuel selector valves were removed and tested using compressed air. The left fuel selector was set to "AUX", and the right fuel selector was set to "MAIN." The Hobbs meter read 4001.1. Complete engine examinations were performed on each engine. The left engine was rotated and thumb compression achieved on all cylinders. The right engine could not be rotated because of ground impact damage; engine continuity was verified by examining the cylinders and engine case by using a bore scope. All magnetos provided spark at all fixtures. Fuel was identified in both engines’ manifold valves. Examination of the wreckage revealed no evidence of preimpact mechanical malfunction. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot on May 11, 2009, by the Washoe County Medical Examiner. The autopsy findings include blunt trauma to the head, abdomen, and upper and lower extremities. The cause of death was reported as “multiple injuries due to blunt force trauma.” Forensic toxicology was performed on specimens collected from the pilot during the autopsy by the Forensic Toxicology Research Team, Oklahoma City, Oklahoma. The results of the analysis were negative for carbon monoxide, cyanide, and ethanol. There were positive results for diphenhydramine, which was detected in blood and the liver. ADDITIONAL INFORMATION Accelerated Stalls (FAA-H-8083-3A, Airplane Flying Handbook) “During flight, the angle of attack of an airplane wing is determined by a number of factors, the most important of which are the airspeed, the gross weight of the airplane, and the load factors imposed by maneuvering. At the same gross weight, airplane configuration, and power setting, a given airplane will consistently stall at the same indicated airspeed if no acceleration is involved. The airplane will, however, stall at a higher indicated airspeed when excessive maneuvering loads are imposed by steep turns, pull-ups, or other abrupt changes in its flightpath. Stalls entered from such flight situations are called “accelerated maneuver stalls,” a term, which has no reference to the airspeeds involved. Stalls which result from abrupt maneuvers tend to be more rapid, or severe, than the unaccelerated stalls, and because they occur at higher-than-normal airspeeds, and/or may occur at lower than anticipated pitch attitudes, they may be unexpected by an inexperienced pilot. Failure to take immediate steps toward recovery when an accelerated stall occurs may result in a complete loss of flight control, notably, power-on spins.” ## Aircraft - Registration: [N1533Z](https://openairdocs.org/deregistered/N1533Z-2013-07-30), registration cancelled 2013-07-30, S/N TC-326, built 1962 (OpenAirDocs) - Reported make and model: BEECH 95 (A55) - Registry model: [Beech 95-A55](https://openairdocs.org/model/beech-95-a55) (registry code 1152704) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TC-326 - Airframe hours: 4001 - Engines: Textron Lycoming O-360 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Gary Annas - Registered owner: Gary Annas - Airworthiness certificate: Standard, Normal - Departed: KMIV, MInden, NV - Destination: KMIV, MInden, NV - Airport: KMIV, Minden-Tahoe Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: fatal; private; airplane ratings: single-engine sea, multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review April 28, 2008; seat: left; toxicology performed; flight hours: 4,700 total ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 8 knots, gusting 14 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 64 °F, dew point 28 °F - Altimeter: 30.09 inHg - Observed at: KTVL, 13 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 20090509007059A](https://openairdocs.org/incident/20090509007059A), May 9, 2009: Beech 95A55, Gardnerville, NV, Destroyed, 5 fatal. (-23) Witnesses reported to the Douglas country sheriff that the pilot had taken four friends that were attending an outdoor working party on a local flight.… ## Docket (13 files) The files NTSB released with the investigation on January 29, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73800. 13.6 MB in all. - Witness Statements (item 1, .PDF, 790 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324634&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Maps or Charts of Accident Area, Wreckage Diagrams - GPS Plot (item 2, .PDF, 281 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323270&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams%20-%20GPS%20Plot-Master.PDF - Photo 1 - Overview, right side (item 3, .PDF, 863 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323271&FileExtension=.PDF&FileName=Photo%201%20-%20Overview,%20right%20side-Master.PDF - Photo 2 - Right rear side (item 4, .PDF, 4.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323272&FileExtension=.PDF&FileName=Photo%202%20-%20Right%20rear%20side-Master.PDF - Photo 3 - Left front view (item 5, .PDF, 809 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323273&FileExtension=.PDF&FileName=Photo%203%20-%20Left%20front%20view-Master.PDF - Photo 4 - Front view (item 6, .PDF, 847 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323274&FileExtension=.PDF&FileName=Photo%204%20-%20Front%20view-Master.PDF - Photo 5 - Cockpit (item 7, .PDF, 844 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323275&FileExtension=.PDF&FileName=Photo%205%20-%20Cockpit-Master.PDF - Photos 6-10 - Photos from hiker (item 8, .PDF, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323276&FileExtension=.PDF&FileName=Photos%206-10%20-%20Photos%20from%20hiker-Master.PDF - Toxicological Report (item 9, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323305&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323307&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323308&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Wreckage Exam Field Notes (item 12, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323309&FileExtension=.PDF&FileName=Wreckage%20Exam%20Field%20Notes-Master.PDF - Pilot Logbook (Extract) (item 13, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323555&FileExtension=.PDF&FileName=Pilot%20Logbook%20(Extract)-Redacted.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.