# NTSB WPR22FA087: Beech K35, N9530R, Salem, OR, January 29, 2022 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: January 29, 2022, 15:02 local (23:02 UTC) - Place: Salem, OR - Coordinates: 44.904994, -122.99854 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.9050&lon=-122.9985&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Abrupt maneuver](https://openairdocs.org/ntsb-events/270) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: FAA - NTSB case key (mKey): 104567 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR22FA087 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104567/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104567 - Page: https://openairdocs.org/ntsb/WPR22FA087 ## Probable cause The airplane’s excessive nose-up pitch attitude during landing for undetermined reasons. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech K35, 1 case](https://openairdocs.org/ntsb-findings/01062022/cases.md?model=1151524), [All aircraft, 526 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Beech K35, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=1151524), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Abrupt maneuver](https://openairdocs.org/ntsb-events/270) (defining event); cases with it: [Beech K35, 1 case](https://openairdocs.org/ntsb-events/270/sequence.md?model=1151524), [All aircraft, 346 cases](https://openairdocs.org/ntsb-events/270/sequence.md) - [Landing: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Beech K35, 2 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1151524), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Landing: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Beech K35, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=1151524), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) ## Analysis The pilot of the accident airplane departed the runway, stating that he was planning to remain in the traffic pattern. The pilot was then cleared to land; on the final approach, after crossing the runway threshold and just before the airplane touched down the airplane pitched up, ascended about 50 ft, and subsequently rolled left before entering a near-vertical descent and then impacting the ground. The airplane’s autopilot was repaired 1.5 flight hours before the accident flight, wherein the auto-pilot pitch servo was sent out for repair, reinstalled, and cable tensions were set. Subsequently, an operational check was conducted, which verified proper installation on the ground. The autopilot pitch servo capability is exhausted by a pitch hold setting, meaning that inadvertent activation would merely maintain the airplane’s present pitch profile at the time of activation. Postaccident examination of the pitch trim actuator revealed a 15° tab down position. The elevator tab limits are 4.5° tab up, to 23° tab down. While the pitch servo had been recently installed, it is not likely that the autopilot was engaged in the airport traffic pattern and specifically during landing. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The cause of the abrupt nose-up pitch attitude during landing could not be determined. Pilot incapacitation was not a factor in this accident. ## Factual narrative A review of FAA Automatic Dependent Surveillance -Broadcast (ADS-B) data revealed that the airplane departed SLE on runway 34 about 4 minutes before the accident and the airplane remained in the airport’s left traffic pattern. The airplane’s flight track indicated that the airplane was established on the final leg of the airport traffic pattern and initiated an approach to runway 34. ADS-B radar returns indicated that the airplane crossed the runway 34 threshold about 175 ft above ground level (agl). The airplane’s ground speed indicated 70 knots as it continued the descent to 150 ft agl, traveling about 660 ft beyond the threshold. Radar returns indicated that during the last seconds of the flight, the airplane ascended to 200 ft agl, at a ground speed of 53 knots, and remained at 200 ft agl until the ground speed decreased to 46 knots, and a subsequent left roll ensued. The last radar return captured in the ADS-B data indicated the airplane’s altitude was 200 ft agl, at a ground speed of 44 knots, about 1 second before impact. A review of the airplane’s engine logbook indicated that the last annual inspection was completed 51.9 hours before the accident flight. A subsequent inspection and service was conducted 15.6 hours before the accident flight, which included an oil change and cleaning of the oil suction screen. According, to an invoice and maintenance entry that had not yet been annotated within the logbook, an engine data monitor (EDM) was installed in the accident airplane 1.5 hours before the accident flight. According to the EDM non-volatile memory (NVM) data files, the accident flight was the second flight since the EDM was installed. Additionally, maintenance records indicated that about the same time that the EDM was installed, maintenance was performed to repair the autopilot pitch servo. The invoice work order indicated that the servo starting voltage and servo motor resistance, “were very much out of limits.” The servo was removed, sent out for repair, reinstalled and cable tensions were set. Subsequently, an operational check was conducted and verified on the ground. A review of the airplane’s airframe logbook indicated that a dual yoke assembly was installed in the airplane during the last annual inspection. However, examination of the airplane revealed that a single throw-over yoke remained installed. The airplane was equipped with an engine data monitor (EDM). The glass panel engine monitor records data using non-volatile (NVM) memory. The NVM data was downloaded from the device which contained the engine parameters of the accident flight, as well as previous flights. The data indicated that normal engine operation parameters were sustained through the entirety of the accident flight in the traffic pattern. The fuel flow, fuel pressure and engine revolutions per minute did not increase while the airplane was on short final or during the last seconds of the accident flight. The engine exhaust gas temperature and cylinder headtemperatures indicated a consistent and continual decrease, throughout the approach. The devices global positioning satellite function was not operational during the accident flight or any previous flight according to the NVM data files. However, the NVM data indicated that the outside air temperature during the accident flight was about 9° C, which was consistent with the reported temperature at the accident airport during the time of the accident. The devices NVM data from the accident flight log indicated a total flight time of 4.2 minutes, which was consistent with the airplane’s ADS-B radar data returns. The device’s NVM data indicated that at the start of the accident flight, the left tank fuel quantity was 14 gallons in the main, and 6.1 gallons in the left auxiliary fuel tank. The right main fuel tank contained 17.8 gallons and the right auxiliary fuel tank contained 8.8 gallons of fuel at the start of the accident flight, according to the NVM data. On January 29, 2022, about 1502 Pacific daylight time, a Beechcraft K35 Bonanza, N9530R, sustained substantial damage when it was involved in an accident near Salem, Oregon. The private pilot and the passenger sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Air traffic control (ATC) recordings confirmed the airplane departures the McNary Field Airport (SLE), Salem, Oregon, about 1458. The SLE weather at the time of the accident was identified as wind 050° at 3 knots, visibility 10 statute miles, with clear skies. The pilot requested to stay in the traffic pattern, and the tower controller instructed the pilot to remain in left closed traffic, subsequently clearing the pilot for takeoff on runway 34. The pilot took off, remained in the traffic pattern, and was cleared by the tower controller to land runway 34. Before touching down on the runway, the tower controller observed the airplane suddenly pitch up and enter a near vertical climb. Subsequently, the airplane veered left and entered a near vertical descent. The airplane impacted the ground, in a near vertical nose-down attitude. The ATC recording of the tower controller’s communication with the pilot revealed that no emergency declaration radio call was transmitted during the sequence of events leading up to the accident. The Marion County Coroner’s Office, Clackamas, Oregon performed an autopsy on the pilot. The autopsy report listed the cause of death as “generalized blunt force trauma,” and the manner of death was an accident. The Federal Aviation Administration Forensic Toxicology Report was negative for all substances tested. No evidence of pilot incapacitation was identified. A review of pilot logbooks indicated that the left seat occupant was an Federal Aviation Administration (FAA) certificated private pilot. The right seat occupant had received some flight training in 1993, and during the months before the accident flight had logged 2.7 flight hours of dualflight instruction with an FAA certificated flight instructor. The occupant in the right seat did not possess a FAA student pilot certificate. The airplane sustained substantial damage to the cabin, forward and aft fuselage, and both wings. The airplane wreckage was located in the grass safety area on the left side of runway 34. The airplane’s left wing impacted the ground about 17 ft from the asphalt runway, as confirmed by the red position light lens fragments that marked the initial point of impact. The airplane’s nose cone, propeller, and engine impacted the ground about 32 ft west of the asphalt runway. The airplane’s nose cone was imbedded into the ground about 10 inches, and two propeller blades were located with the propeller hub. One propeller blade separated from the hub and was found in the impact crater. The engine remained attached to the firewall and main wreckage, which consisted of the fuselage, both wings with the left and right main landing gear attached, and the empennage. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The nose landing gear sustained impact damage, but the left and right main landing gear were extended and locked. The leading edges of both wings were crushed aft with virtually symmetrical impact damage. The left and right flaps were fully extended at 30° and the aileron direct cables were intact from the wing bellcranks to the control chain sprocket in the cockpit. The aileron chain was separated at the sprocket with evidence of the chain being pulled apart. The left aileron wing bellcrank arm attached to the interconnect cable was fractured at the bellcrank. No evidence of fatigue was observed in the fracture surface. The pitch trim actuator revealed a 15° down position. The elevator tab limits are 4.5° tab up, to 23° tab down. The ruddervator cables were continuous from the cockpit controls to the control surfaces. The left and right ruddervators, and the elevator trim tabs did not sustain impact damage. ## Aircraft - Registration: [N9530R](https://openairdocs.org/deregistered/N9530R-2023-04-01), registration cancelled 2023-04-01, S/N D-6077, built 1959 (OpenAirDocs) - Reported make and model: BEECH K35 - Registry model: [Beech K35](https://openairdocs.org/model/beech-k35) (registry code 1151524) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-6077 - Year built: 1959 - Airframe hours: 6351 - Engines: CONT MOTOR IO-470-C 250 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 24, 2021, 51.9 hours before - Airport: SLE, Mcnary Fld, runway 34, 5,146 × 100 ft, asphalt - Equipment: Auto-pilot, ADS-B, Data recorder ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review October 5, 2020; seat: left; restraint: none; flight hours: 1,155 total, 647.5 in this make and model, 632.8 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 50° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 48 °F, dew point 34 °F - Altimeter: 30.23 inHg - Observed at: KSLE - METAR: KSLE 292256Z 05003KT 10SM CLR 09/01 A3023 RMK AO2 SLP237 T00940006 ## 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 20220129001289A](https://openairdocs.org/incident/20220129001289A), Jan 29, 2022: Beech K35, Salem, OR, Substantial damage, 2 fatal. The pilot requested a t/o, closed pattern and landing from sle tower. According to witnesses, as the aircraft entered the flare it pitched up, climbed… ## Docket (13 files) The files NTSB released with the investigation on January 4, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104567. 1.7 GB in all. - ATC srt (item 1, PDF, 1 page, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15655547&FileExtension=pdf&FileName=sle%20-%20fatal%20accident%20with%20atc%20services%20-%20srt-Rel.pdf - ADS-B tabular data (item 2, CSV, 391 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15618185&FileExtension=csv&FileName=14031_20220129225500_Once-Rel.csv - N9530R engine data monitor -tabular data (item 3, XLSX, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15618712&FileExtension=xlsx&FileName=N9530R%20Engine%20Data%20Monitor-Rel.xlsx - Airframe and engine examination report (item 4, PDF, 8 pages, 182 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15699791&FileExtension=pdf&FileName=N9530R%20Airframe%20and%20Engine%20Examination%20Summary-Rel.pdf - Engine logbook (item 5, PDF, 10 pages, 282 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15656179&FileExtension=pdf&FileName=Engine_Redacted-Rel.pdf - Airframe logbook (item 6, PDF, 20 pages, 734 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15655664&FileExtension=pdf&FileName=Airframe_Redacted-Rel.pdf - Propeller logbook (item 7, PDF, 7 pages, 224 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15699835&FileExtension=pdf&FileName=Propeller_Redacted-Rel.pdf - Autopilot operating handbook (item 8, PDF, 84 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15733942&FileExtension=pdf&FileName=Autopilot%20Operating%20Handbook-Rel.pdf - Pilot logbook (item 9, PDF, 20 pages, 356 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15656200&FileExtension=pdf&FileName=D.%20McKenna%20Logbook%20Experience_Redacted-Rel.pdf - Passenger logbook (item 10, PDF, 8 pages, 111 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15656105&FileExtension=pdf&FileName=C.%20McKenna%20Flight%20Experience_Redacted-Rel.pdf - Party member certification form tai (item 11, PDF, 1 page, 517 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15552071&FileExtension=pdf&FileName=NTSB%20Party%20Form%20WPR22FA087%20TAI_Redacted-Rel.pdf - Autopsy memorandum for record (item 12, PDF, 1 page, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15658058&FileExtension=pdf&FileName=Autopsy%20Memo%20for%20Record%20WPR22FA087-Rel.pdf - Pilot toxicology report (item 13, PDF, 1 page, 349 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15552016&FileExtension=pdf&FileName=Pilot%20Toxicology%20Report_Redacted-Rel.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.