National Transportation Safety Board - Aviation Accident Final Report: http://app.ntsb.gov/pdf
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http://registry.faa.gov/N9200S
NTSB Identification: ERA12FA526
14 CFR Part 91: General Aviation
Accident occurred Sunday, August 26, 2012 in Dayton, VA
Probable Cause Approval Date: 12/05/2013
Aircraft: BEECH B24R, registration: N9200S
Injuries: 1 Fatal.
NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
Before departing on the accident flight, the noninstrument-rated pilot obtained a weather briefing and was advised several times that visual flight rules (VFR) flight was not recommended due to existing and forecast instrument meteorological conditions (IMC) along his intended route of flight. The pilot then departed on a VFR flight without filing a flight plan. More than 2 hours after departure, the pilot contacted air traffic control (ATC) and advised that he was climbing the airplane from 9,000 to 10,500 feet. Two minutes later, the pilot declared an emergency and advised ATC that he had "lost" the engine. The controller provided vectors to nearby airports, attempting to orient the pilot to the airplane's position relative to the airports so that he could acquire the airports visually. However, the pilot advised that he was "still in the soup and can't see much of anything at this point." About 5 minutes later, the pilot stated that the airplane was unable to clear a ridgeline in its flightpath, and shortly thereafter, radar and voice communication with the airplane was lost. The airplane collided with trees and terrain before reaching a suitable landing site.
Examination of the wreckage and engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. The fuel tanks were intact, and about 1 pint of fuel was drained from the left tank and 10 gallons were drained from the right. The fuel selector was found positioned to the right tank. Continuity of the entire fuel system was confirmed. Disassembly of the gascolator found that it contained no fuel, was completely dry, and was absent of debris. At the time of departure, each fuel tank contained 26.1 gallons of usable fuel. According to the manufacturer's pilot operating handbook, the airplane would consume 10.2 gallons per hour at 75 percent maximum continuous power. Given the fuel capacity of each tank, continuity of the fuel system, dry fuel system components, and published fuel consumption rates, it is likely the pilot exhausted the fuel supply in the left tank. It is likely that the engine lost power due to fuel starvation, and the pilot switched the fuel selector to the right tank but was unable to restore engine power before encountering a ridgeline in IMC. Toxicological testing and a review of the pilot's medical records revealed the contraindicated use of anti-depressant medication, which was not declared on his most recent medical certificate application.
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's improper fuel management, which resulted in fuel starvation and a total loss of engine power. Contributing to the accident was the noninstrument-rated pilot's decision to attempt a visual flight rules flight in instrument meteorological conditions over mountainous terrain.
HISTORY OF FLIGHT
On August 26, 2012, about 1118 eastern daylight time, a Beech B24R Sierra, N9200S, was substantially damaged when it collided with trees and terrain during a forced landing after a reported loss of engine power near Dayton, Virginia. The certificated private pilot was fatally injured. Instrument meteorological conditions (IMC) prevailed, and no flight plan was filed for the personal flight that originated from Wilmington International Airport (ILM), Wilmington, North Carolina, at 0903. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.
At 0831 the morning of the accident, the pilot phoned the Raleigh Automated Flight Service Station (AFSS) and obtained a preflight weather briefing. During the briefing, he was advised multiple times that visual flight rules (VFR) flight was not recommended due to existing and forecast IMC along his intended route of flight. The pilot departed at 0903 without filing a flight plan.
According to the Federal Aviation Administration (FAA), at 1109, the pilot contacted air traffic control, and advised that he was climbing the airplane from 9,000 to 10,500 feet. At 1111, the pilot declared an emergency, advised he had “lost” the engine, and stated that he was "VFR on top."
The controller initially provided vectors to Bridgewater Airpark (VBW), Bridgewater, Virginia, and then to Frank Field (VA52), Harrisonburg, Virginia. He attempted to orient the pilot to the airplane’s position relative to the two airports, so that he could acquire the airports visually, but at 1112, the pilot advised he was "still in the soup and can't see much of anything at this point." At 1117, the pilot stated that the airplane was unable to clear a ridgeline in its flight path and shortly thereafter, radar and voice communication with the airplane was lost. At that time, the airplane was located on a bearing 301 degrees and 8 nautical miles from VBW.
PERSONNEL INFORMATION
The pilot/owner held a private pilot certificate with a rating for airplane single engine land. His most recent FAA third-class medical certificate was issued on November 2, 2010. He reported 600 total hours of flight experience on that date. The pilot’s logbook was recovered and reviewed at the accident site. Examination revealed the pilot had logged approximately 235 total hours of flight experience, of which 206 hours were in the accident airplane. The pilot did not possess an instrument rating.
AIRCRAFT INFORMATION
According to FAA records, the airplane was manufactured in 1975, and had accrued 3,206.9 total aircraft hours. The most recent annual inspection was completed November 19, 2011, at 3,192.5 aircraft hours.
METEOROLOGICAL INFORMATION
At 1115, the weather conditions reported at Shenandoah Valley Regional Airport (SHD), located 15 miles southeast of the accident site at 1,201 feet elevation, included scattered clouds at 1,800 feet, a broken ceiling at 3,300 feet, and an overcast ceiling at 4,000 feet. There was 10 miles visibility; the temperature was 22 degrees C, dew point 18 degrees C, and an altimeter setting of 30.24 inches of mercury. The wind was from 100 degrees at 4 knots.
WRECKAGE INFORMATION
The wreckage was examined at the accident site on August 26, 2012, at 1,869 feet elevation, and all major components were accounted for at the scene. There was no odor of fuel or evidence of fuel spillage. The wreckage path was oriented 245 degrees magnetic, and was about 60 feet in length. The initial impact point was in a treetop about 40 feet above the ground. The second tree strike was approximately 20 feet farther along the wreckage path, about 20 feet above the ground. The 4-inch trunk displayed a sharp, angular cut with paint transfer consistent with the paint on the propeller blades. The initial ground scar was about 55 feet along the wreckage path, and immediately in front of the airplane, which came to rest, upright, and facing opposite the direction of travel.
The engine, firewall, instrument panel, and cockpit areas showed significant impact damage and airframe deformation. The leading edges of both wings displayed aft crushing, and about 4 feet of the outboard section of each wing was separated. Control cable continuity was established from the cockpit to the rudder and elevator. Cable continuity was established through cable breaks to the ailerons. All cable breaks displayed failure due to overload.
The fuel tanks were intact, and about one pint of fuel was drained from the left tank while 10 gallons was drained from the right. The fuel selector was in the right tank position. Continuity of the entire fuel system was confirmed. The gascolator was removed and disassembled. It contained no fuel, was completely dry, and was absent of debris. The fuel boost pump, as well as the boost pump switch, was destroyed by impact.
The engine was recovered from the scene and examined at SHD on August 28, 2012. The engine was partially disassembled to facilitate examination due to impact damage to the inlet air box, and the intake and exhaust tubes. The engine was rotated by hand and continuity was established through the powertrain and valvetrain to the accessory section. Compression was confirmed on all cylinders using the thumb method. Borescope examination of each cylinder revealed no anomalies. The magnetos were removed, rotated by hand, and produced spark at all terminal leads. The engine-driven fuel pump was removed, actuated by hand, and pumped fluid.
The fuel flow divider was removed and disassembled. The flow divider contained a few drops of fuel and was absent of debris. The fuel injector lines and nozzles for each cylinder were clear and absent of debris.
The fuel injector servo was impact damaged, and the mixture and throttle control settings could not be determined.
MEDICAL AND PATHOLOGICAL INFORMATION
The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing for the pilot. The following Tested-for-Drugs were detected:
Fluoxetine and Norfluoxetine were detected in blood and urine.
Fluoxetine (Prozac) belonged to a class of drugs called selective serotonin reuptake inhibitors (SSRIs). It was used in adults for the treatment of major depressive disorder, panic disorder, obsessive-compulsive disorder, bulimia (eating disorder), treatment-resistant depression, and depression associated with bipolar disorder. In children and adolescents, fluoxetine was used to treat major depression and obsessive-compulsive disorder.
Norfluoxetine was a metabolite of Fluoxetine.
Examination of the pilot’s personal and FAA medical records revealed that Norfluoxetine was prescribed to the pilot by a physician, but that he did not disclose its use on his most recent application for an FAA medical certificate.
The Office of the Chief Medical Examiner for the Commonwealth of Virginia, performed an autopsy on the pilot in Roanoke, Virginia. The cause of death was the result of blunt force trauma to the head and chest.
ADDITIONAL INFORMATION
At the time of the accident, there was an active AIRMET SIERRA for mountain obscuration for the area surrounding the accident site. Based on infrared satellite imagery from GOES-13 at 1115, cloud top temperatures in the immediate vicinity of the accident location ranged between 6 degrees C to 9 degrees C. Interpolation of rawinsonde data from a 0800 launch at Sterling, Virginia, revealed these temperatures corresponded to cloud-top heights of approximately 9,000 to 7,200 feet, respectively.
The airplane was equipped with one 29.9 gallon fuel tank in each wing. Of the 59.8 gallons on board, 52.2 gallons were usable. According to the manufacturer's pilot operating handbook, Section V – Performance, Cruise Power Settings, at 75 percent maximum continuous power (or full throttle), the nominal fuel flow was 10.2 gallons per hour.
NTSB Identification: ERA12FA526
14 CFR Part 91: General Aviation
Accident occurred Sunday, August 26, 2012 in Dayton, VA
Aircraft: BEECH B24R, registration: N9200S
Injuries: 1 Fatal.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.
On August 26, 2012, about 1118 eastern daylight time, a Hawker-Beechcraft Corporation B24R Sierra, N9200S, was substantially damaged when it collided with trees and terrain during a forced landing after a reported loss of engine power near, Dayton, Virginia. The certificated private pilot was fatally injured. Visual meteorological conditions (VMC) prevailed, and no flight plan was filed for the personal flight that originated from Wilmington International Airport (ILM), Wilmington, North Carolina. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.
Preliminary information from the Federal Aviation Administration (FAA) revealed that at 1109, the pilot contacted air traffic control, and advised that he was climbing the airplane from 9,000 to 10,500 feet. At 1111, the pilot declared an emergency and advised he had “lost” the engine. The controller provided vectors to Bridgewater Airpark (VBW), Bridgewater, Virginia, but the pilot advised that the airplane was unable to clear a ridgeline in his path. At 1117, radar and voice communication with the airplane was lost. At that time, the airplane was 8 nautical miles from VBW.
The pilot/owner held a private pilot certificate with a rating for airplane single engine land. His most recent FAA third class medical certificate was issued on November 2, 2010, and he reported 600 total hours of flight experience on that date. Examination of his logbook revealed the pilot had logged approximately 235 total hours of flight experience, of which 206 hours were in the accident airplane. The pilot did not posses an instrument rating.
At 1115, the weather conditions reported at Shenandoah Valley Regional Airport (SHD), 15 miles southeast of the accident site at 1,201 feet elevation, included scattered clouds at 1,800 feet, a broken ceiling at 3,300 feet, and an overcast ceiling at 4,000 feet. There was 10 miles visibility; the temperature was 22 degrees C, dewpoint 18 degrees C, and an altimeter setting of 30.24 inches of mercury. The wind was from 100 degrees at 4 knots.
The wreckage was examined at the accident site on August 26, 2012, at 1,869 feet elevation, and all major components were accounted for at the scene. There was no odor of fuel or evidence of fuel spillage. Control cable continuity was established from the cockpit to the flight control surfaces.
The fuel tanks were intact, and about one pint of fuel was drained from the left tank while 10 gallons was drained from the right. The fuel selector was in the right tank position. Continuity of the entire fuel system was confirmed. The gascolator was removed and disassembled. It contained no fuel, was completely dry, and was absent of debris. The fuel boost pump switch was destroyed in the instrument panel, and the boost pump was destroyed by impact.
The engine was recovered from the scene and examined at SHD on August 28, 2012. The engine was rotated by hand and continuity, compression, and ignition spark were all confirmed.
ROCKINGHAM COUNTY, Va -- Brian Forrest Hall reached out for help right before he crashed his plane on Sunday morning.
"He contacted air traffic control and the pilot stated that he had lost his engine," said Brian Rayner with the National Transportation Safety Board (NTSB).
“I lost my engine,” were Hall's last words on the air. Rayner said they are trying to figure out what those words meant.
“Then minutes later, the airplane was lost from radar," said Rayner.
The 50-year-old man from Pittsburgh crashed in the George Washington National Forest around 11:30 a.m. on Sunday morning. He was supposed to stop in Harrisonburg before heading to Pennsylvania.
Right now, the NTSB is picking up the pieces to find out the cause of the accident.
“My focus right now is on the perishable evidence, which is the airplane behind me.”
The plane is a 1975 single engine Beechcraft, but Rayner said if a plane is well-maintained, age will not affect the plane's reliability.
“A 1975 Beechcraft could be as good or potentially better than it was when it rolled off the assembly line.”
That is why they will look into the maintenance and pilot records.
Rayner said they have seen accidents like this in this part of the country before but each one is different.
"When we come out to these investigations. We investigate them one at a time. We are not interested in looking at trends until we're well into it."
Investigators say they will work with the plane manufacturers to find out if the plane was faulty. They should know more once the preliminary report is released next week.
Rayner said the entire investigation could last up to a year.
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