# NTSB WPR22FA332: Beech 58, N142DR, Galt, CA, September 4, 2022 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: September 4, 2022, 08:40 local (15:40 UTC) - Place: Galt, CA - Coordinates: 38.30462, -121.35155 - Nearby events: https://openairdocs.org/map.md?lat=38.3046&lon=-121.3516&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Textron Aviation, Federal Aviation Administration, Textron - NTSB case key (mKey): 105854 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR22FA332 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105854/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105854 - Page: https://openairdocs.org/ntsb/WPR22FA332 ## Probable cause The certified flight instructor's failure to maintain control of the airplane and inadequate supervision of the flight, which resulted in an aerodynamic stall/spin from which he could not recover. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Instructor/check pilot; cases with it: [Beech 58, 15 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1152740), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Beech 58, 3 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=1152740), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Beech 58, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=1152740), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Maneuvering: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Beech 58, 3 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=1152740), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Maneuvering: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech 58, 19 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1152740), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot under instruction and the certified flight instructor (CFI) departed in the multi-engine airplane to conduct training. Radar data indicated that they proceeded to multiple airports and performed traffic pattern work including takeoff and landings. After departing the last airport, they performed two 360° turns and one power off stall task. The airplane again slowed and recorded engine data indicated that, while the critical engine’s speed was reduced, the other engine’s speed was increased, consistent with performing a Vmc demonstration. During a Vmc demonstration, power is reduced on the critical engine (left) and the airplane is recovered before loss of directional control or stall. As the airspeed decreased, the airplane entered a rapid descent with a continuous left-hand turn that was observed by witnesses as it was spinning, not nose down, with a flat attitude until water impact. Impact signatures were consistent with a slightly nose-low, near-flat attitude. Postaccident examination of the engines and airframe did not reveal evidence of any mechanical malfunctions or anomalies that would have precluded normal operation of the airplane. Positive identification of who was on the controls during the Vmc demonstration could not be determined given the available evidence. ## Factual narrative The airplane’s POH/AFM stated in part, “Single engine minimum controllable airspeed (Vmca): 84 knots indicated airspeed.” “Practice demonstration of Vmca. Vmca demonstration may be required for multi-engine pilot certification. The following procedures shall be used at a safe altitude of at least 5000 feet above the ground in clear air only.” 1. Landing Gear – Up 2. Flaps – Up 3. Airspeed – Above 88 kts (Vsse) 4. Propeller Levers – High RPM 5. Throttle (Simulated inoperative engine) – Idle 6. Throttle (Other engine) – Maximum Manifold Pressure 7. Airspeed – Reduce approximately 1 knot per second until either Vmca or stall warning is obtained. CAUTION Use rudder to maintain directional control (heading) and ailerons to maintain 5° bank towards the operative engine (lateral attitude). At the first sign of either Vmca or stall warning (which may be evidenced be: inability to control heading or lateral attitude, aerodynamic stall buffet, or stall warning speaker sound) immediately initiate recovery: reduce power to idle on the operative engine and immediately lower the nose to regain Vsse.” The Federal Aviation Administration (FAA) Private Pilot – Airplane Airmen’s Certification Standards, Task B. Vmc Demonstration (AMEL, AMES) stated, in part, “S1f. Power on critical engine reduce to idle and propeller windmilling. S1g. Power on operating engine set to takeoff or maximum power available. S3. Establish a single-engine climb attitude with the airspeed of approximately 10 knots above Vsse.” FAA Advisory Circular AC 61-67C, dated, January 6, 2016, stated, in part, “A flat spin is characterized by a near level pitch and roll attitude with the spin axis near the [center of gravity] CG of the airplane. Recovery from a flat spin may be extremely difficult and, in some cases, impossible. The FAA Airplane Flying Handbook (FAA-H-8083-3C) stated, in part, “The AFM/POH-published VMC is determined with the critical engine inoperative. The critical engine is the engine whose failure had the most adverse effect on directional control. On twins with each engine rotating in conventional, clockwise rotation as viewed from the pilot's seat, the critical engine will be the left engine.” Following a series of fatal accidents in Beech Baron- and Travel Air-series airplanes, the National Transportation Safety Board issued Safety Recommendations A-81-49 through -53 on May 7, 1981, because of the propensity of these airplanes to enter flat spins under conditions of high asymmetric power and low speed. Training for a potential emergency, such as an engine-out condition, "may be more hazardous than the emergency itself." In 1974, the U.S. Army issued a report on the stall characteristics of the Beech T-42A, which is like the B55B and D95A airplanes. Section 3, page 6, of the Beech D95A Owner's Manual states: "This is a normal category airplane. Maneuvers, including spins, are prohibited." Section 4, page 9, states: "If a spin is entered inadvertently, cut the power on bothengines. Apply full rudder opposite the direction of rotation and then move the elevator forward until rotation stops. When the controls are fully effective, bring the nose up smoothly to a level flight attitude. Don't pull out too abruptly." On September 4, 2022, about 0840 Pacific daylight time, a Beech BE-58 airplane, N142DR, was substantially damaged when it was involved in an accident near Galt, California. The pilot and the pilot under instruction were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 flight. Automatic dependent surveillance broadcast (ADS-B) data captured the airplane as it departed McClellan Airfield (MCC) Sacramento, California about 0707. The airplane then traveled to Calaveras County Airport (CPU), San Andreas, California, where it arrived about 0726, landed, then departed. It then traveled to Modesto City-County Airport (MOD), Modesto, California, where it arrived about 0750, flew over the runway and then departed. The airplane continued to Tracy Municipal Airport (TCY), Tracy, California where it arrived about 0811. The airplane landed, took off staying in the traffic pattern, landed again, then departed about 0823. The airplane climbed to an altitude of 4,800 ft mean sea level (msl), maintained about 180 knots ground speed, and proceeded to the northeast. About 0834, the airplane, while about 4,750 ft and 173 knots, performed a 360° turn to the right followed by a 360° turn to the left (figure 1). After the 360° turns the airplane continued to the northeast, climbed to 5,000 ft and maintained about 170 knots. ADS-B data showed that at 0837:34, the airplane reduced its speed to about 80 knots. About the same time the engine data monitor (EDM) recorded the left and right engine fuel flows reduced from about 18.5 gallons per hour (gph) to about 2 to 4 gph. About 2 seconds after the airspeed reached 80 knots, the airplane began to accelerate to 151 knots, and the altitude began to decrease from 4,975 ft to 4,825 ft. At the same time, the fuel flow increased from 2 to 4 gph to about 26 gph (figure 2). ADS-B data revealed that about 0839, the airplane began a second speed reduction. The EDM recorded the fuel flow on the left engine as it decreased from about 20 GPH to about 3 GPH, while the right engine’s fuel flow increased from about 18 GPH to about 29 GPH. About 20 seconds later the right engine’s fuel flow reduced from about 29 GPH to zero GPH. At 0840:01 the airplane’s altitude of about 4,825 msl, or about 4725 ft agl, began to decrease rapidly as the airplane entered a left continuous turn. The speed continued to reduce and the descending left turn continued until data was lost at 0840:45. The last data point captured the airplane about 22 ft agl and about 3 knots almost directly above the accident site. Figure 1. ADS-B data showing the right and left 360° turns followed by a segment of flight about 4700 ft agl, with a speed reduction followed by a steep, near verticaldescent. The blue arrows point in the direction of travel. Figure 2. A graphic illustration from the engine data monitor showing the reduction of fuel flow to the left engine and the increase of fuel flow to the right engine. The times are based on EDM time. About the same time, multiple witnesses, who were hunting about a mile from the accident site, reported seeing the airplane spinning or rotating. One indicated that “it was flatter than nose down.” Another witness stated that “there was no engine noise, [the] engine was completely off.” Another stated that he heard the engine then the engine stopped and a minute later it started coming down in circles. A records and ADS-B data review revealed that the crew conducted a flight on September 3, 2022, the day before the accident. The flight consisted of maneuvers at multiple airports and flight maneuvers consistent with training. There were no indications of the crew conducting a Vmc demonstration task. The duration of the flight was about 2.1 hours. An autopsy of the CFI was conducted by the Sacramento County Coroner, Sacramento, California. The cause of death was blunt force injuries. An autopsy of the pilot under instruction was conducted by the Sacramento County Coroner, Sacramento, California. The cause of death was multiple blunt force injuries. The CFI was seated in the right seat. His complete personal flight logs were not available for examination. Photos of some pages were received by a family member; however, no data was contained to quantify his experience in multi-engine airplanes or the model of the accident airplane. He reported 15,500 hours flight experience on his last flight physical and was authorized to exercise the privilege of a specialty aircraft examiner (SAE) and designated pilot examiner (DPE) for the FAA. The CFI’s paper calendar was recovered from the wreckage, and it revealed the pilot under instruction’s last name was written in on September 3, and 4, 2022. There were no other dates with the pilot under instruction’s name documented in the CFI’s calendar. The pilot under instruction was seated in the left seat. He held a certificate for single engine land airplanes and was not rated in multi-engine airplanes. His personal logbook was not recovered. He reported 10.0 hours flying experience on his last medical examination. The airplane came to rest on a magnetic heading of 270°, in a narrow body of water mostly covered with aquatic vegetation. There were no ground scars leading into the water and only the vegetation immediately around the airplane appeared disturbed. All major components remained attached to the airplane except for the left propeller, which separated from the engine at the crankshaft. The one-piece windshield was shattered, and the cabin structure was displaced slightly over the left wing. The underside of the fuselage and the underside of both wings exhibited substantial upward crushing throughout with minimum aft crushing. The empennage exhibitedminor damage and was displaced to the right. Both engines remained attached to the wings and both propellers were feathered. Flight control continuity was established for all flight controls, from the control surfaces to their respective controls in the cockpit. All breaks in the flight control components were consistent with overload forces. The landing gear was found in the retracted position. No mechanical malfunctions or failures were found that would have precluded normal operation. ## Aircraft - Registration: [N142DR](https://openairdocs.org/aircraft/N142DR), registered now, S/N TH-1458, built 1985 (OpenAirDocs) - Reported make and model: BEECH 58 - Registry model: [Beech 58](https://openairdocs.org/model/beech-58) (registry code 1152740) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Airplane - Serial number: TH-1458 - Year built: 1985 - Engines: Continental IO-550-C reciprocating; Continental IO-550-C reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Registered owner: Hj & L Air LLC - Airworthiness certificate: Standard, Normal - Departed: TCY, Tracy, CA - Equipment: ADS-B, Auto-pilot, Onboard weather, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 68; injuries: fatal; commercial, flight instructor, airline transport, remote; airplane ratings: multi-engine sea, single-engine sea, multi-engine land, single-engine land; instrument ratings: airplane, helicopter; medical: class 2, with waivers/limitations; seat: right; restraint: 3-point; toxicology performed; flight hours: 15,500 total, 1,000 in this make and model - Pilot; age 56; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; restraint: 3-point; toxicology performed; flight hours: 10 total, 3.6 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 290° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 77 °F, dew point 55 °F - Altimeter: 29.90 inHg - Observed at: KSAC, 14 nm away - METAR: KSAC 041553Z 29005KT 10SM CLR 25/13 A2990 RMK AO2 SLP123 T02500133 ## 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 20220904015119A](https://openairdocs.org/incident/20220904015119A), Sep 4, 2022: Beech 58, Galt, CA, Destroyed, 2 fatal. Aircraft[privacy data omitted], multi engine, retractable tricycle gear, lost directional control at approximately 4,600 ft MSL during an apparent… ## Docket (14 files) The files NTSB released with the investigation on April 25, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105854. 62.8 MB in all. - Engine data monitor-specialist's factual report (item 1, PDF, 13 pages, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16972328&FileExtension=pdf&FileName=WPR22FA332%20Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - Attachment 1 to engine data monitor - specialist's factual report (item 2, CSV, 156 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15270147&FileExtension=csv&FileName=WPR22FA332%20Attachment%201%20to%20Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report-Rel.csv - Witness statements (item 3, PDF, 2 pages, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16779080&FileExtension=pdf&FileName=FW_%20Plane%20Crash%20SSO%20Report%23%2022-263040_Redacted-Rel.pdf - Interviews (item 4, PDF, 4 pages, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16776267&FileExtension=pdf&FileName=Interviews-Rel.pdf - Airframe and engine examination report (item 5, PDF, 24 pages, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16971517&FileExtension=pdf&FileName=Airframe%20and%20Engine%20Examination%20WPR22FA332-Rel.pdf - Manufacturer's examination report (item 6, PDF, 11 pages, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16780960&FileExtension=pdf&FileName=Tech%20Report%20TH-1458_Redacted-Rel.pdf - Pic's logbook excerpts (item 7, PDF, 3 pages, 10.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16756461&FileExtension=pdf&FileName=CFI%27s%20Log%20Book%20Entries_Redacted-Rel.pdf - Pic's loa (item 8, PDF, 6 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16779465&FileExtension=pdf&FileName=PIC%27s%20LOA_Redacted-Rel.pdf - ADS-B data September 3, 2022 (item 9, KMZ, 345 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16780950&FileExtension=kmz&FileName=20220903_A0AA79_494221896-Rel.kmz - ADS-B excel data September 3, 2022 (item 10, CSV, 21.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16745987&FileExtension=csv&FileName=59668_20220903144000_Once-Rel.csv - ADS-B data September 4, 2022 (item 11, KMZ, 279 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16747050&FileExtension=kmz&FileName=20220904_A0AA79_494294826_ADSB-Rel.kmz - ADS-B excel data September 4, 2022 (item 12, CSV, 15.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16747380&FileExtension=csv&FileName=20220904_A0AA79_494294826_ADSB-Rel.csv - Statement of party representatives to NTSB investigation (item 13, PDF, 1 page, 198 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16747370&FileExtension=pdf&FileName=CERTIFICATION%20OF%20PARTY%20REPRESENTATIVE_Redacted-Rel.pdf - Toxicological reports (item 14, PDF, 2 pages, 325 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16776312&FileExtension=pdf&FileName=Tox%20Report%20All_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.