WPR19FA150

NTSB accident investigation · Beech 35 · Melba, ID · May 19, 2019

Accident · FatalClass 3 · FieldFinal report
Date
May 19, 2019, 15:08 local (21:08 UTC)
Place
Melba, ID
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N1888DBeech 35
Defining event
Initial climb: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, Textron Aviation, Continental Motors
FAA report
20190519004869A
Case key
99449

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot's loss of control during a low-level aerobatic maneuver, which resulted in impact with terrain. Contributing to the accident was the pilot’s impairment due to the effects of alcohol and antidepressant medication.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotBeech C35: 5 casesAll aircraft: 9,295 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech C35: 1 caseAll aircraft: 1,269 casesProbable cause
Impairment/incapacitation: alcoholPersonnel issues › Physical · PilotBeech C35: 1 caseAll aircraft: 87 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

Shortly after takeoff in his airplane that was not approved for aerobatics, the airline transport pilot performed an aileron roll about 500 ft above ground level. He departed the airport traffic pattern, then returned and landed about 15 minutes later. The pilot taxied the airplane back to the runway and initiated another takeoff, during which he leveled off and accelerated the airplane about 50 ft above the ground, retracted the landing gear, and initiated a climb and an aileron roll. A witness reported that, about 135° into the maneuver, the airplane stopped rolling, then entered a descent that continued until ground impact. Postaccident examination of the airplane and engine revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation. Toxicological testing of the pilot revealed impairing levels of ethanol in addition to two impairing antidepressant medications. The circumstances of the accident are consistent with the pilot's loss of control during a low-level aerobatic maneuver. It is likely that the pilot's recent alcohol ingestion and his use of antidepressant medications affected his decision making and attention and contributed to the accident.

Factual narrative

The accident airplane was a four-place, all metal, low-wing, single-engine monoplane equipped with retractable tricycle landing gear. The airplane was powered by a Continental Motors E-225 engine, serial number 30610-D-5-8, and rated at 225 horsepower at 2,650 rpm. The airplane's maintenance records were not located. According to the Pilot Operating Handbook, the airplane was not approved for aerobatic flight. On May 19, 2019, about 1508 mountain daylight time, a Beech C35, N1888D, was substantially damaged when it was involved in an accident near Melba, Idaho. The airline transport pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. A pilot-rated witness reported that the accident pilot departed from runway 30 and turned onto the downwind leg of the traffic pattern, where pilot performed a barrel roll to the right. The witness saw the airplane climb to 500 ft above ground level (agl) over the canyon to the north of the airport and proceed in that direction. After about 15 minutes, the witness noticed the airplane approach the airport from the north at normal pattern altitude and subsequently land on runway 30. After landing, the pilot taxied to runway 30 and commenced a takeoff. The airplane accelerated, lifted off, and the nose remained low as the airplane accelerated, remaining about 50 ft above the ground. The pilot retracted the landing gear, and shortly thereafter, the airplane entered a climb and a right aileron roll at the end of the runway. When the airplane rolled through about 135°, it stopped rolling, then nosed down behind a tree line at an approximate 45° angle. The witness stated that he did not observe the impact, and that “… the engine continued to run after impact, although this sound could have been reflected off the canyon wall from across the river.” The Owyee County Coroner’s Office, Marsing, Idaho, performed an autopsy on the pilot. The cause of death was attributed to severe blunt force trauma. Postmortem toxicological testing by the coroner’s office detected ethanol in the pilot’s cavity blood at 0.164 grams per deciliter (gm/dL) and liver tissue at 0.110 grams per hectogram (gm/hg). The antidepressants duloxetine and trazodone were detected in cavity blood at 320 nanograms per milliliter (ng/mL) and 160 ng/mL, respectively. Trazodone and trazodone’s active metabolite, meta-chlorophenylpiperazine (mCPP), were also detected in liver tissue. Toxicological testing by the Federal Aviation Administration (FAA) Forensic Sciences Laboratory was positive for ethanol in cavity blood (0.168 gm/dL), brain tissue (0.094 gm/hg), and muscle tissue (0.103 gm/hg). Duloxetine, trazodone, and mCPP were detected in cavity blood (336 ng/mL, 175 ng/mL, and 15 ng/mL, respectively) and urine at (141 ng/mL, 227 ng/mL, and 111 ng/mL, respectively). Ethanol acts as a central nervous system depressant; it impairs judgment, psychomotor functioning, and vigilance. Ethanol iswater soluble, and after absorption it quickly and uniformly distributes throughout the body’s tissues and fluids. The effects of ethanol on aviators are generally well understood; it significantly impairs pilots’ performance, even at very low levels. While the acute effects of ethanol can vary depending on an individual's frequency of use, body weight, and tolerance, in general, at blood ethanol concentrations as low as 0.02 gm/dL there is relaxation and some loss of judgment and at 0.05 gm/dL there is further degradation of judgment, psychomotor functioning, and alertness. 14 CFR Part 91.17(a) prohibits any person from acting or attempting to act as a crewmember of a civil aircraft while having 0.040 gm/dL or more ethanol in the blood. Duloxetine, commonly marketed as Cybalta, is a prescription medication used to treat depression, anxiety, and chronic musculoskeletal pain. Duloxetine carries the warning that its use may impair mental and physical ability to perform potentially hazardous tasks. The therapeutic range is 22 to 55 ng/mL and it has a half-life of 8 to 17 hours. Trazodone is a prescription medication used to treat depression and anxiety. Trazodone can be sedating. It comes with this warning, “Trazodone hydrochloride tablets may cause somnolence or sedation and may impair the mental and/or physical ability required for the performance of potentially hazardous tasks. Patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that the drug treatment does not affect them adversely.” Trazodone is metabolized to an active metabolite, mCPP. Trazodone may enhance the response to alcohol, barbiturates, and other central nervous system depressants. The therapeutic range is 500 to 2,500 ng/mL and it has a half-life of 4 to 7 hours. About 1456, the weather reporting station located at the Caldwell Industrial Airport (EUL), Caldwell, Idaho, about 14 nautical miles north-northeast of the accident site, reported calm wind, 10 miles visibility, light rain, broken clouds at 1,100 ft agl, overcast clouds at 4,600 ft agl, temperature 12°C, dew point 10°C, and an altimeter setting of 29.59 inches of mercury. The pilot held an airline transport pilot certificate with a rating for airplane multiengine land; commercial privileges for airplane single-engine land and single-engine sea; and a flight instructor certificate for airplane single-engine, multiengine and instrument airplane. The pilot also held a flight engineer certificate for reciprocating engine powered aircraft. The pilot's most recent third-class medical certificate was issued July 28, 2011, with a limitation for corrective lenses. On the application for that medical certificate, the pilot reported 20,000 hours total flight experience, with 0 hours flown in the previous six months. The medical certificate expired for all classes on July 31, 2013. The pilot completed the requirements for BasicMed certification on November 9, 2018.The pilot's logbook was not available for review. The airplane impacted terrain about 1,045 ft from the end of the runway, aligned with the runway extended centerline. Following the initial impact, the airplane rotated clockwise about 180° as it slid about 90 ft, where it came to rest upright on a magnetic heading of about 130°, about 72 ft north of the runway extended centerline. The cabin and cockpit areas were consumed by postcrash fire. The left wing remained attached to the fuselage. Soot was observed on the top inboard 3 ft of the wing surface. The remainder of the wing’s leading edge was not damaged. The inboard 18 inches of the left flap displayed soot but was otherwise undamaged and was in the retracted position. The left aileron was impact damaged and was separated from the trailing edge of the wing. The wingtip fuel tank remained attached to the wing and displayed impact damage. The main fuel tank was breached and consumed during the accident sequence and postcrash fire. The right wing, including the tip tank, was destroyed as a result of impact with terrain. The wing separated from the forward wing root attach point but remained attached at the aft wing root attach point. The right flap remained attached to the wing’s trailing edge and was impact damaged. The right aileron completely separated from the wing’s trailing edge during the accident sequence. The fuel tank was breached and consumed during the accident sequence and postcrash fire. The cabin/cockpit area, from the instrument panel to just aft of the aft cabin bulkhead, was entirely consumed by fire. The underside of the aft fuselage was bent and deformed, with only minor damage on its upper surface. The empennage, including both left and right stabilizers, ruddervators, and their trim tabs, was undamaged. Control continuity was established from all control surfaces to the cockpit control yoke. Both left and right main landing gear and the nose landing gear were retracted. Each sustained substantial damage due to impact forces incurred during the accident sequence. The engine was separated from its mount during the accident sequence. Examination of the engine revealed no anomalies that would have precluded normal operation. The propeller flange remained attached to the crankshaft, with one blade attached to the propeller and secured in its hub and the second blade missing from its hub; the second blade was located about three months after the accident about 220 ft east-northeast of the main wreckage. The attached blade was twisted and bent forward. The separated blade was twisted and bent aft. The cambered side of the separated blade appeared polished, consistent with having passed soft soil in which the blade was located through.

Aircraft

Registration
N1888D
Reported as
Beech 35 (C35)
Category
Airplane
Serial number
D-3160
Built
1952
Engine
Continental E185, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Departed
ID40 · Melba, ID
Destination
ID40 · Melba, ID
Airport
ID40 · Sunrise Airpark Airport, runway 30, 2,892 × 40 ft, asphalt
Equipment
Unknown

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
71
Injuries
Fatal
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
BasicMed, With waivers/limitations
Seat
Left
Restraint
Lap only
Toxicology
Performed
Flight hours
20,000 total · 200 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
1,100 ft broken
Temperature
54 °F, dew point 50 °F
Altimeter
29.59 inHg
Observed at
EUL, 14 nm away

Docket · 10

The files NTSB released with the investigation on June 17, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 33.4 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N1888D · 1

Matched to the same aircraft by N-number and date.