Thursday, December 21, 2017

Beech A36 Bonanza, N72054: Fatal accident occurred December 11, 2015 near Nemacolin Airport (PA88), Farmington, Wharton Township, Fayette County, Pennsylvania

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Pittsburgh, Pennsylvania
Textron Aviation; Wichita, Kansas
Continental Motors; Mobile, Alabama

Aviation Accident Final Report - National Transportation Safety Board:  https://app.ntsb.gov/pdf

Investigation Docket  - National Transportation Safety Board: https://dms.ntsb.gov/pubdms


Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf

Terry Allen Carlson:  http://registry.faa.gov/N72054 

Location: Farmington, PA
Accident Number: ERA16FA064
Date & Time: 12/11/2015, 1422 EST
Registration: N72054
Aircraft: BEECH A36
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 3 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis 

The private pilot and two passengers were departing on a cross-country flight. Witness statements and data from an onboard GPS indicated that, after takeoff, the airplane turned left and entered the downwind leg of the airport traffic pattern for the departure runway. The airplane climbed to a maximum altitude about 500 ft above ground level (agl), then entered a gradual descent as it continued downwind and entered a left base leg. Witnesses noted that the landing gear was extended. The final data points from the GPS indicated that the airplane was conducting a tight turn from the base to final legs of the traffic pattern at a low airspeed and an altitude about 200 ft agl. The airplane crashed in a heavily wooded area near a golf course. It is likely that, during the final turn, the airplane exceeded its critical angle of attack and experienced an aerodynamic stall. A passenger, who was severely burned but able to egress the airplane following the accident, advised first responders that the cabin door had opened just after takeoff.

Examination of the wreckage revealed no evidence of any mechanical malfunction of the airplane or engine prior to the accident. The forward cabin door's upper latching mechanism (hook) was not fully extended; the slot in the upper fuselage frame, which the hook engaged when the door was closed, showed no evidence of tear-outs; and the door handle mechanism was not fully in the locked position. These findings are consistent with the cabin door being open at the time of impact.

The airplane's pilot's operating handbook (POH) advised that the forward cabin door could unlatch in flight if not properly secured; this could occur during or just after takeoff. Although the door would open about 3 inches, the flight characteristics of the airplane would not be affected, with the exception of a reduced rate of climb. The POH advised that, if the door opened in flight, the pilot should "return to the field in a normal manner."

Twenty-two years before the accident flight, the airplane manufacturer published a mandatory service bulletin after receiving reports of the lower aft latch pin on the cabin door retracting in flight due to misrigging and/or vibration. When the latch pin retracted, it would force the entire door latching mechanism to reverse, allowing the door to open. This service bulletin, which had not been accomplished on the accident airplane, would have modified the forward cabin door to reduce the possibility of a cabin door opening in flight.

Toxicological testing on specimens from the pilot identified amphetamine at 0.310 ug/ml and 0.347 ug/ml in blood and 1.828 ug/ml in urine. This is well above any therapeutic range, which is less than 0.20 ug/ml. Generally, levels above 0.20 are the result of misusing amphetamine to maximize its psychoactive effects. In addition, phenylpropanolamine was detected in the pilot's urine, which suggests that he obtained the drug from non-pharmaceutical sources. An autopsy identified thickening of the heart walls and minimal coronary artery disease; however, this was unlikely to have caused acute symptoms. The thickening of the heart walls was likely caused by the increased workload related to repeated episodes of increased heart rate and blood pressure resulting from amphetamine use. It is possible that these two conditions (thickened heart and significant levels of amphetamine) combined to cause a sudden arrhythmia (a specific risk with amphetamine) which could have caused palpitations or fainting, resulting in the pilot's loss of control of the airplane. Such an event would not have left evidence that could be identified on autopsy.

It could not be determined whether the pilot was experiencing the euphoria of early phase response to amphetamine or the dysphoria of coming down from its effects. In either case, the effects are significantly impairing and affect the ability to concentrate, make safe decisions, and perform.

Regardless of the reason the door opened in flight, the airplane should have remained airworthy and controllable. Although the pilot was attempting to return to land as prescribed by the POH following a door opening event, he did not safely manage the airplane's airspeed and angle of attack and lost control of the airplane. The investigation could not determine whether the pilot's impaired judgement or an acute arrhythmia caused by his misuse of amphetamine led to his inability to safely land the airplane; however, in either case, the pilot's misuse of amphetamine contributed to the accident. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to maintain control of the airplane after a cabin door came open in flight, which resulted in the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall. Contributing to the accident was the pilot's misuse of amphetamine.

Findings

Aircraft
Performance/control parameters - Not attained/maintained (Cause)
Passenger/crew doors - Not specified

Personnel issues
Aircraft control - Pilot (Cause)
Illicit drug - Pilot (Factor)
Decision making/judgment - Pilot

Factual Information 

HISTORY OF FLIGHT

On December 11, 2015, about 1422 eastern standard time, a Beech A36, N72054, was destroyed when it impacted trees and terrain shortly after takeoff from Nemacolin Airport (PA88), Farmington, Pennsylvania. The private pilot and two passengers were fatally injured. The airplane was privately owned and operated under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the personal flight, which was destined for Montgomery County Airport (GAI), Gaithersburg, Maryland.

PA88 was located on the property of the Nemacolin Woodland Resort. A witness who was staying at the resort, who viewed the airplane from his hotel room which was located on the northwest side of the runway reported that, after takeoff from runway 23, the airplane's landing gear retracted, and the airplane appeared to be departing the area; however, the airplane continued to turn as if entering the downwind leg of the traffic pattern. The landing gear extended, and the airplane began to descend. The airplane continued to descend in a turn consistent with a left base for runway 23; the witness then lost sight of the airplane behind terrain. Shortly after, he observed smoke. Another witness who was standing about 2,500 ft southeast of the runway saw the airplane pass overhead with the landing gear down. He stated that the airplane was "pretty low" and that the engine sounded normal. He saw the airplane bank to the left, and then he lost sight of it behind buildings; he then heard an impact and saw flames and smoke.

An onboard GPS recorded data for the accident flight. The recording began at 1415:57 near the airport parking area. The airplane subsequently taxied to the end of runway 23 for takeoff. Recorded GPS altitude at this time was about 1,975 ft. The takeoff roll began at 1420:18. At 1421:00, at a GPS altitude of 2,184 ft and about 2,500 ft from the departure end of the runway, the airplane began a left, climbing turn. The turn continued, and the airplane reached a maximum recorded altitude of 2,457 ft at 1421:36. At this time, its position was consistent with a left downwind for runway 23. The airplane descended as it continued the downwind leg, then began a left turn about 1422. Shortly thereafter, the airplane descended through 2,150 ft at 69 knots groundspeed. The last recorded data point was at 1422:22.

About 1423, landscaping personnel called the resort's security dispatch and reported the accident. Security personnel arrived to find the airplane fully engulfed in flames and one passenger laying outside of the airplane on the golf course.

The passenger, who was severely burned during the accident, had egressed from the airplane by himself and was pulled from the accident site by resort guests. He advised first responders that his father (who was flying the airplane) and his friend were onboard the airplane. He remembered taking off from the runway, the door opening and feeling wind, and then being surrounded by flames. He was transported to a burn center and succumbed to his injuries about 2 days later.

PERSONNEL INFORMATION

According to Federal Aviation Administration (FAA), and pilot records, the pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane, and a commercial pilot certificate with ratings for helicopter and instrument helicopter. His most recent application for an FAA third-class medical certificate was dated February 22, 2014. The pilot had accrued about 3,261 total hours of flight experience, of which 2,663 hours were in the accident airplane make and model.

AIRCRAFT INFORMATION

According to FAA airworthiness records and airplane maintenance records, the airplane was manufactured in 1984. The airplane's most recent annual inspection was completed on November 11, 2015. At the time of the inspection, the airplane had accrued about 4,448.5 total hours of operation, and the engine had accrued about 1,158.8 total hours of operation since major overhaul.

METEOROLOGICAL INFORMATION

The 1435 reported weather at Garrett County Airport (2G4), Oakland, Maryland, located 17 nautical miles southeast of the accident site, included wind from 250° at 11 knots gusting to 19 knots, 10 miles visibility, broken clouds at 1,300 ft, temperature 11°C, dew point 8°C, and an altimeter setting of 29.95 inches of mercury.

AIRPORT INFORMATION

PA88 was located about 1 mile east of Farmington, Pennsylvania. It was classified by the FAA as a privately owned, private-use airport. The airport elevation was 2,010 ft above mean sea level and the asphalt runway was configured in a 5/23 orientation. The runway measured 3,980 ft long by 49 ft wide. The runway 23 threshold was displaced 935 ft due to trees off the approach end of the runway. The runway was equipped with medium intensity runway edge lights, and a precision approach path indicator system which, at the time of the accident, was disabled.

FLIGHT RECORDERS

The accident airplane was equipped with a handheld Garmin GPSMAP 39x/49x series GPS.

The unit had suffered extreme thermal damage, but an internal examination revealed the non-volatile memory chip was intact, and data from the accident flight was extracted.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest in a heavily wooded area located next to a golf course.

Examination of the accident site revealed that the airplane had broken apart after striking trees in a left-wing-down, nose-low attitude. During the impact sequence, the main cabin portion of the airplane traveled about 152 ft before impacting the forest floor and coming to rest, facing the opposite direction of travel, with the aft fuselage and empennage lying behind it in an inverted position. The engine, left outboard wing, right wing flap, right main landing gear, and engine cowlings were all separated from their mounting positions and were strewn throughout the accident site. Further examination also revealed the presence of propeller strikes on broken tree branches and tree trunks that littered the ground, along with areas of burned underbrush and fire-damaged trees.

Examination of the wreckage revealed that the landing gear was in the down position, and all major portions of the airplane's structure were present at the accident site. No evidence of any preimpact failure of the airplane structure was discovered.

Examination of the flight control system revealed no evidence of any preimpact failure or malfunction, and flight control continuity was established from the flight control surfaces to the rudder pedals and control wheels through breaks in the system consistent with overstress failure.

Examination of the fuel system revealed that all four fuel caps were closed and locked, and the fuel selector valve was in the left main tank position.

Examination of the propeller and engine also revealed no evidence of any preimpact failure or malfunction that would have precluded normal operation. The propeller remained attached to the propeller flange and exhibited a circumferential fracture just aft of the propeller flange. All three blades exhibited S-bending, twisting, and chordwise scratching. Oil was present in the rocker boxes and oil sump, and the oil filter was absent of debris. Crankshaft and valve train continuity was confirmed, and compression and suction were observed on all six cylinders.

Examination of the interior of the cylinders with a lighted borescope did not reveal evidence of any preimpact damage to the piston domes, cylinder walls, or valves. Both magnetos were functional and produced spark at all towers.

Examination of the remains of the utility doors, which were located on the aft right side of the fuselage, and the forward cabin door, which was located on the forward right side of the fuselage, revealed that most of the door structures had been burned away. Further examination revealed that the locking mechanisms were present and did not show any evidence of malfunction or failure.

Examination of the forward cabin door revealed that the upper latching mechanism (hook) was not fully extended, and the slot in the upper fuselage frame that the hook engaged when the door was closed showed no evidence of tear-outs. Further examination also revealed that the door handle mechanism was not fully in the locked position; the lower aft latch pin, which rode in a guide inside the lower aft portion of the forward cabin door and engaged a receptacle in the lower door sill, was missing.

MEDICAL AND PATHOLOGICAL INFORMATION

According to FAA airman medical records, during his last medical examination, the pilot reported that he had no chronic medical conditions and was on no medications.

According to the report of the autopsy performed by Cyril H. Wecht and Pathology Associates, Inc., Pittsburgh, Pennsylvania, the cause of death was multiple blunt force injuries and the manner of death was accident. The autopsy identified minimal coronary artery disease with about 10-15% stenosis. The heart weight was not provided, but the right ventricular wall was described as 0.4-cm thick, the left ventricular wall as 1.5-cm thick, and the septum as 1.3-cm thick. Average for these thicknesses is 0.3 cm, 1.23 cm, and 1.23 cm, respectively. The remainder of the examination was unremarkable.

Toxicology testing performed at the request of the medical examiner by NMS Labs identified caffeine and 0.310 ug/ml of amphetamine in the pilot's blood.

Toxicology testing performed by the FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, identified amphetamine at 0.347 ug/ml in blood and 1.828 ug/ml in urine, as well as phenylpropanolamine in urine, but not in blood.

Amphetamine is a Schedule-II controlled substance that stimulates the central nervous system. It is available by prescription for the treatment of attention deficit disorder and narcolepsy. It carries a boxed warning about its potential for abuse and has warnings about an increased risk of sudden death and the potential for mental health and behavioral changes. Commonly marketed names include Adderall, Dexedrine, and Vyvanse. After a single 30 mg oral dose, early blood levels averaged 0.111 ug/ml and average blood levels in adults using the long acting prescription orally for a week were about 0.065 ug/ml. Generally, levels above 0.2 are the result of misusing amphetamine to maximize its psychoactive effects.

Amphetamine is also prepared and used as a street drug, often by snorting, inhaling, or injecting. Street preparations may begin with phenylpropanolamine, which may then contaminate the final product.

In the early phase, amphetamine misusers may experience a combination of euphoria, excitation, exhilaration, rapid flight of ideas, increased libido, rapid speech, motor restlessness, hallucinations, delusions, psychosis, insomnia, reduced fatigue or drowsiness, increased alertness, a heightened sense of well-being, stereotypes behavior, feelings of increased physical strength, and poor impulse control. Heart rate, blood pressure, and respiratory rate increase, and they may have palpitations, dry mouth, abdominal cramps, twitching, dilated pupils, faster reaction times, and increased strength. As the initial effects wear off, users commonly experience dysphoria, restlessness, agitation, and nervousness; they may experience paranoia, violence, aggression, a lack of coordination, delusions, psychosis, and drug craving.

Phenylpropanolamine is a sympathomimetic also in the amphetamine class that was once available in over-the-counter preparations for treating colds. However, it also increases heart rate and blood pressure, and its availability in the United States was discontinued in 2000. It remains available as a veterinary medicine.

ADDITIONAL INFORMATION

Materials Laboratory Examination

On May 4, 2016, the latching mechanism for the door of the airplane was examined in the NTSB Materials Laboratory. Deposits were observed on the external surfaces of the latching mechanism that were consistent with soot and other combustion products. Using a 5x to 50x stereo-zoom microscope, the fracture surfaces were examined. The fracture surface features were consistent with overstress related to incipient melting.

Pilot's Operating Handbook - Forward Cabin Door

The airplane's pilot's operating handbook (POH) stated that, when closed, the spring-loaded outside cabin door handle would fit into a recess to create a flat, aerodynamically clean surface. It could be locked from the outside with a key to secure the airplane.

The door could be opened from the outside by lifting the handle out of the recess and pulling until the door opened.

When closing the door from the inside of the airplane, the door handle was moved to the open position. In this position, the latch handle would be free to move about 1 inch in either direction before engagement of the locking mechanism. The door could then be grasped and firmly pulled closed, and the handle could then be fully rotated counterclockwise into the locked position. When the door was properly locked, the door latch handle would be free to move about 1 inch in either direction.

The POH noted that, when checking the door latch handle, "do not move it far enough to engage the doorlatch release mechanism." The POH also advised to press firmly at the top rear corner of the door and that, if any movement of the door was detected, to completely open the door, and close it again by following the instructions.

When exiting the airplane, the door could be opened from the inside by depressing the lock button, and rotating the handle clockwise.

The "BEFORE TAKEOFF" checklist contained in the POH included the item, "Doors and Windows – SECURE."

According to the POH, if the cabin door was not properly latched, it could unlatch in flight. This could occur during or just after takeoff. The door would trail open approximately 3 inches and result in a reduced rate of climb, but the flight characteristics of the airplane would otherwise not be affected. The procedure for an unlatched door in flight was to "Return to the field in a normal manner."

Beechcraft Mandatory Service Bulletin

In 1993, Beechcraft had received reports of the third latch pin (lower aft latch pin) on the cabin door retracting in flight due to misrigging and/or vibration. When the latch pin retracted, it would force the entire door latching mechanism to reverse, allowing the cabin door to open.

As a result, in September 1993, Beechcraft released Mandatory Service Bulletin No. 2457, which required that Kit 36-4007 be installed to modify the cabin door by adding a third latch pin overcenter mechanism, modify the bellcrank assembly for the third latch pin, and replace the original third latch pin guide assembly with a redesigned one to reduce the possibility of a cabin door opening in flight.

Comparison of the accident airplane's internal door locking mechanism to an exemplar internal door locking mechanism revealed that the door had not been modified in accordance with the mandatory service bulletin. Review of the airplane maintenance records also did not indicate that the mandatory service bulletin had been accomplished.

The pilot's spouse advised that they had the "door light" come on a few times before the accident, and that the door was hard to latch.

Review of the POH indicated that the annunciator panel in the airplane contained three annunciators placarded "LOW BUS VOLTS", "START", and "AFT DOOR." No indication of an annunciator being mounted in the panel for the forward cabin door was discovered.

Air Speed Information

Review of the GPS data showed that the airplane's groundspeed dropped to 69 knots prior to its rapid descent. Calculations using the wind vector solutions function of an E6-B flight computer indicated that the true airspeed of the airplane at that point, would have been about 79 knots, which was below the published stall speed in the Beechcraft Bonanza Pilot's Operating Handbook (POH) for banked turns in excess of about 45°.

History of Flight

Prior to flight
Miscellaneous/other

Initial climb
Miscellaneous/other

Approach-VFR pattern base
Loss of control in flight (Defining event)

Uncontrolled descent
Collision with terr/obj (non-CFIT)

Post-impact
Fire/smoke (post-impact) 

Pilot Information

Certificate: Commercial; Private
Age: 68, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Helicopter
Restraint Used: Unknown
Instrument Rating(s): Airplane; Helicopter
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 02/22/2014
Occupational Pilot: No
Last Flight Review or Equivalent: 11/01/2014
Flight Time: 3261 hours (Total, all aircraft), 2663 hours (Total, this make and model) 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: BEECH
Registration: N72054
Model/Series: A36 UNDESIGNATED
Aircraft Category: Airplane
Year of Manufacture: 1984
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: E-2181
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 11/11/2015, Annual
Certified Max Gross Wt.: 3651 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 4448.5 Hours as of last inspection
Engine Manufacturer: Continental
ELT: C91  installed, not activated
Engine Model/Series: IO-550-B78
Registered Owner: On file
Rated Power: 300 hp
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: 2G4, 2933 ft msl
Observation Time: 1425 EST
Distance from Accident Site: 17 Nautical Miles
Direction from Accident Site: 135°
Lowest Cloud Condition:
Temperature/Dew Point: 11°C / 8°C
Lowest Ceiling: Broken / 1300 ft agl
Visibility: 10 Miles
Wind Speed/Gusts, Direction: 11 knots/ 19 knots, 250°
Visibility (RVR):
Altimeter Setting: 29.95 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Farmington, PA (PA88)
Type of Flight Plan Filed: IFR
Destination: GAITHERSBURG, MD (GAI)
Type of Clearance:
Departure Time: 1420 EST
Type of Airspace: Class G 

Airport Information

Airport: Nemacolin Airport (PA88)
Runway Surface Type: Asphalt
Airport Elevation: 2010 ft
Runway Surface Condition: Dry
Runway Used: 23
IFR Approach: None
Runway Length/Width: 3980 ft / 49 ft
VFR Approach/Landing: Precautionary Landing; Traffic Pattern 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 2 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Fatal

Latitude, Longitude:   39.813889, -79.535278

NTSB Identification: ERA16FA064 
14 CFR Part 91: General Aviation
Accident occurred Friday, December 11, 2015 in Farmington, PA
Aircraft: BEECH A36, registration: N72054
Injuries: 3 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. 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.

On December 11, 2015, at approximately 1420 eastern daylight time, a Beech A36; N72054, was Destroyed when it impacted trees and terrain after a loss of control during a return to the airport, after takeoff from Nemacolin Airport (PA88), Farmington, Pennsylvania, The certificated private pilot was fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the Title 14 Code of Federal Regulations Part 91 personal flight, destined for Montgomery County Airport (GAI), Gaithersburg, Maryland.

According to witness statements, after departure from runway 23 at PA88, the landing gear on the airplane was observed to retract, and the airplane "made a sudden turn like it was trying to turn around." The landing gear then extended into the down position. The airplane was next observed turning onto a close in, left base leg for runway 23 "pretty low" to the ground, about 800 yards from the Nemacolin Woodlands Resort Outdoor Animal Exhibits Area, and then was lost from sight as it passed behind the resort's Panoramic Pavilion. Moments later the sound of the airplane impacting trees and then the ground was heard, and a "fireball" and smoke was observed to rise into the air.

The airplane came to rest in a heavily wooded area located next to the 11th fairway of the resort's Links Golf Course and was subject to a postcrash fire.

Examination of the accident site revealed that the airplane had broken apart after striking trees in a left wing down, nose low attitude. During the impact sequence, the main cabin then traveled approximately 152 feet before impacting the forest floor and coming to rest, facing the opposite direction of travel, with the aft fuselage and empennage lying behind it in an inverted position. The engine, left outboard wing, right wing flap, right main landing gear, and engine cowlings, were all separated from their mounting positions and were strewn throughout the accident site. Further examination also revealed the presence of propeller strikes on broken off tree branches and tree trunks that littered the ground, along with areas of burned underbrush and fire damaged trees.

Examination of the wreckage revealed that the landing gear was in the down position, and all major portions of the airplane's structure were present at the accident site. No evidence of any preimpact failure of the airplane structure was discovered.

Examination of the flight control system revealed no evidence of any preimpact failure or malfunction and flight control continuity was able to be established from the flight control surfaces, to the breaks in the system, and from the breaks in the system, to the rudder pedals and control wheels.

Examination of the fuel system revealed that all four fuel caps were closed and locked, and the fuel selector valve was in the left main tank position.

Examination of the propeller and engine also revealed no evidence of any preimpact failure or malfunction that would have precluded normal operation. The propeller remained attached to the propeller flange and a circumferential fracture just aft of the propeller flange was present. All three blades exhibited S-bending, twisting, and chord wise scratching. Oil was present in the rocker boxes and oil sump, and the oil filter was absent of debris. Crankshaft and valve train continuity was confirmed and compression and suction was observed on all six cylinders. Examination of the interior of the cylinders with a lighted borescope did not reveal evidence of any preimpact damage to the piston domes, cylinder walls, or valves. Both magnetos were functional, and produced spark at all towers.

Examination of the remains of the utility doors which were located on the aft right side of the fuselage and the forward cabin door which was located on the forward right side of the fuselage revealed that the majority of the doors structures had been burned away. Further examination revealed however, that the locking mechanisms were made of steel, were present.

Examination of the utility doors locking mechanism did not show any evidence of malfunction or failure.

Examination of the forward cabin door revealed that the upper latching mechanism (hook) was not fully extended, and the slot in the upper fuselage frame that the hook engaged when the door was closed, showed no evidence of tear-outs. Further examination also revealed that the door handle mechanism was not fully in the locked position. The bayonet which engaged the lower door sill was not recovered.

According to Federal Aviation Administration (FAA) and pilot records, the pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane, and a commercial pilot certificate with ratings for helicopter and instrument helicopter. His most recent application for a FAA third-class medical certificate was dated February 22, 2014. The pilot reported that he had accrued approximately 3,261 total hours of flight experience, of which 2,663 hours were in the accident airplane make and model.

According to FAA and airplane maintenance records, the airplane was manufactured in 1984. The airplane's most recent annual inspection was completed on November 11, 2015. At the time of the inspection, the airplane had accrued approximately 4,448.5 total hours of operation, and the engine had accrued approximately 1,158.8 total hours of operation since major overhaul.

Terry Carlson



 A plane crash on the grounds of a posh Pennsylvania resort that killed three Maryland men stemmed from a front cabin door opening during takeoff, federal investigators have concluded.

The National Transportation Safety Board said the open door caused the small plane to stall and crash shortly after takeoff from Nemacolin Woodlands Resort in December 2015, the Pittsburgh Tribune-Review reported .

Investigators said in a report recently made public that 68-year-old pilot Terry Carlson, of Kensington, Maryland, attempted to return to land as prescribed after the door opened but "did not safely manage the airplane's airspeed and angle of attack and lost control of the plane."

The report said Carlson, who owned the Beechcraft BE 36 single-engine plane, likely was under the influence of an amphetamine, which could have caused palpitations or fainting, resulting in his "loss of control of the plane."

Carlson and 26-year-old Jason Willems, of Silver Spring, Maryland, died in the crash. Carlson's 27-year-old son, Erick Carlson, of Rockville, Maryland, died a day later.

Erick Carlson told firefighters at the scene that the cabin door opened "just after takeoff," investigators said. The forward cabin door's upper latching mechanism was not fully extended in the wreckage, the report said.

The report noted Terry Carlson was a veteran pilot certified by the Federal Aviation Administration. It noted Carlson's widow told investigators after the crash that he had served in Vietnam and had flown Hueys for the Army and later in the National Guard for several years.

"Her husband loved flying and was very experienced," the report said. "She advised that they had the 'door light' come on a few times before and that the door was hard to latch."

The resort was built by 84 Lumber founder Joe Hardy and includes a golf course, a luxury hotel, a casino and an airfield, among other amenities. It has a 3,800-foot-long (1,158-meter-long) runway, suitable for smaller planes, according to its website.


The two men who died in a plane crash at Nemacolin Woodlands Resort were employees for a consulting firm based in Reston, Va., the company confirmed Saturday.

“With a heavy heart, Capital Edge Consulting announces the death of team members Terry Carlson and Jason Willems in a fatal plane crash Friday afternoon,” Capital Edge consulting said in a statement. “Erick Carlson, the third passenger, is in critical condition and is currently being treated for his injuries.”

The company has offices in Sewickley, Denver and San Diego. It provides consulting services for private companies that contract with government agencies, including the Air Force.

Officials from UPMC Mercy were not available to discuss Erick Carlson's condition.

“We are all devastated at the loss of these two Capital Edge family members,” Capital Edge CEO and Managing Director Chad Braley said in a statement. “We ask for your understanding and privacy for our team and the families as we all mourn this loss and pray for the recovery of Erick Carlson and the impacted families.”

Source: http://triblive.com





FARMINGTON, Pa —  Two men were killed and a third man severely burned when a small plane crashed at the posh Nemacolin Woodlands Resort in southwestern Pennsylvania.

First responder dispatch calls reveal emergency crews were on the scene of a plane crash near Nemacolin Woodlands Resort in minutes.

Shortly after the Beech 36 Bonanza took off from the resort's private airstrip, one of the doors on the plane malfunctioned, came off and hit the plane’s wing. The plane then crashed, hitting trees and catching fire.

Pilot Terry Carlson, of Kensington,. Maryland., and Jason Willems, 26, of Silver Spring, Maryland., died in the crash. Terry Carlson's son Erik Carlson, 27, of Rockville, Maryland., survived the crash and was flown to Mercy Hospital with severe burns.





Two people died and one was injured when a small aircraft crashed Friday afternoon in a forested area off of Woodcock Road near a private airstrip owned by the Nemacolin Woodlands Resort, according to a Fayette County dispatcher.

“A Beech 36 Bonanza crashed about one-half mile from Nemacolin Airport in Farmington, Pa., at about 2:15 p.m. today,” Jim Peters of the Federal Aviation Administration said in an email. “The accident occurred shortly after the aircraft took off from the private airstrip.”

An aerial photo of the site showed the plane broken into several pieces in a broad area just inside a tree line next to a field. A medical helicopter was called to the scene for treatment of the injured person, who was flown to UPMC Mercy in Pittsburgh, the dispatcher said. The Fayette County coroner was also called.

Brian VanSickle, the Farmington Volunteer Fire Chief, told reporters at the resort that he and four fellow firefighters were hunting within several hundred yards from where the plane crashed.

“It sounded like an engine malfunction,” he said.

“I didn't know what it was. The woods filled with white smoke and we could hear bystanders hollering,” VanSickle said.

VanSickle said he and the other firefighters rushed to the crash scene where several resort security staffers were already on the scene.

He said the one surviving occupant had self-extricated. He didn't specify who the victim was.

VanSickle said he did not get a chance to speak with the victim before he or she was transported by helicopter to UPMC Mercy Hospital in Pittsburgh.

The two dead people were pronounced dead at the scene by county coroner's office personnel.

Pennsylvania State Police have secured the scene until federal investigators arrive Saturday morning. Federal Aviation Administration and National Transportation Safety Board personnel are expected to arrive early Saturday.

Peters would not confirm casualties or injuries.

Resort employees during the day were directing non-emergency personnel and visitors away from the site of the crash, which they said was in a “very hard to access” area at the resort.

Monte Hansen, managing director at the resort, said there was no public access to the wooded site where the plane crashed, so access was limited to emergency personnel only.

“Our thoughts and prayers are with all of those affected by this accident. We are working with first responders and will provide more information as soon as it becomes available,” Hansen said.

Officials have not released the names of the people on board at the time the private, four-passenger aircraft crashed. The single-engine aircraft is registered to Terry A. Carlson of Kensington, Md., according to FAA records.

The National Transportation Safety Board will investigate the cause of the crash with the assistance of FAA investigators, according to NTSB spokesman Terry Williams. He said determining a probable cause of the accident will take approximately a year.

The private airstrip at the 2,000-acre resort about 62 miles southeast of Pittsburgh is 3,845-feet long and 49-feet wide, according to the resort's website. There is also a warning to pilots that the airstrip is closed from dusk to dawn each day and during bad weather conditions.

The Federal Aviation Administration (FAA) released the following statement:

A Beechcraft BE36 aircraft crashed about one-half mile from Nemacolin Airport in Farmington, PA at about 2:15 pm today. The accident occurred shortly after the aircraft took off from the private airstrip.  Check with local authorities on the condition of the three people on board. The FAA will investigate and the National Transportation Safety Board (NTSB) will determine the probable cause of the accident.

Statement of Nemacolin Woodlands Resort:

This afternoon at approximately 2:15 p.m., a Beech 36 Bonanza airplane leaving Nemacolin’s airfield crashed after takeoff in a residential area adjacent to our resort’s golf course.

There are reports of fatalities, but we have no official confirmation of damages, injuries or fatalities. We are working with first responders and will provide more information as soon as it is available.

There is no public access to the crash site as fire and public safety officials continue their work.

Our thoughts and prayers are with all of those affected by this accident.
======

Erick Carlson loved to fly and especially liked to fly with his father, who was a certified pilot, a cousin said.

“Flying was one of his passions,” said the cousin, William “Billy” Wakeham, 28, of Vancouver, Wash.

Carlson, 27, of Rockville, Md., died at 5:20 p.m. Saturday at UPMC Mercy, Uptown. He was the only survivor of a plane crash Friday near the Nemacolin Woodland resort in Fayette County that claimed the life of his father and one of Erick Carlson's best friends.

Terry Carlson, 68, of Kensington, Md., and Jason Willems, 26, of Maryland died when the Beech A36 Bonanza plane crashed not far from a private airstrip owned by Nemacolin Woodlands.

Fayette Coroner Dr. Phillip Reilly said he is not releasing the cause of death for Terry Carlson and Willems pending further investigation and contacting family members.

Terry Carlson was a managing director and Willems was a consultant at Capital Edge, a consulting firm based in Reston, Va., that has offices in Sewickley, Denver and San Diego. It provides consulting services to private companies that contract government agencies. Willems' LinkedIn page states that he has been with the company since February.

Wakeham said he didn't know why the trio were in Pennsylvania and why Erick was with them. Erick Carlson died of burns, according to a supervisor at the Allegheny County Medical Examiner's Office.

Erick Carlson loved all kinds of outdoor adventure, from skydiving to skiing, said Wakeham, who said he saw his cousin most recently last summer.

“He touched everybody's life who met him,” Wakeham said Sunday.

Kim Carlson, Erick Carlson's mother and the wife of Terry Carlson, is “devastated,” Wakeham said.

The crash occurred at 2:55 p.m. Friday in a heavily wooded section of Wharton, where the resort is located. The plane had left from the airstrip, and witnesses said it caught fire upon impact. Torn metal was strewn over a large area of rough terrain near a resort golf course.

The Beech A36 Bonanza plane was registered to Terry Carlson, a veteran pilot certified by the Federal Aviation Administration.

The National Transportation Safety Board has an investigator on the site and expects to release information Monday about the plane's destination, said Terry Williams, a spokesman for NTSB. The evaluation of the accident could take a year to complete, a safety board spokesman said.

Williams said the safety board could not confirm reports that one of the plane's doors came off after takeoff and hit the plane's wings, forcing it down. It still is early in the investigation, Williams said.

Resort officials have not disclosed whether the men had been guests or attended an event at Nemacolin.

Jeff Nobers, a corporate spokesman for Nemacolin Woodlands, could not be reached for comment Sunday.


Source:  http://triblive.com

Managing director Monte Hansen speaks to the media about a plane crash that killed two people on Thursday, Dec. 11, 2015, at Nemacolin Woodlands Resort in Farmington. 


Farmington fire chief Brian Van Sickle speaks to the media about a Beech 36 Bonanza crash that killed two people on Thursday, Dec. 11, 2015, at Nemacolin Woodlands Resort in Farmington.
























































Terry Allen Carlson
~

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Pittsburgh, Pennsylvania
Textron Aviation; Wichita, Kansas
Continental Motors; Mobile, Alabama

Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket  - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

Terry Allen Carlson:  http://registry.faa.gov/N72054 



Location: Farmington, PA
Accident Number: ERA16FA064
Date & Time: 12/11/2015, 1422 EST
Registration: N72054
Aircraft: BEECH A36
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 3 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

HISTORY OF FLIGHT

On December 11, 2015, about 1422 eastern standard time, a Beech A36, N72054, was destroyed when it impacted trees and terrain shortly after takeoff from Nemacolin Airport (PA88), Farmington, Pennsylvania. The private pilot and two passengers were fatally injured. The airplane was privately owned and operated under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the personal flight, which was destined for Montgomery County Airport (GAI), Gaithersburg, Maryland.

PA88 was located on the property of the Nemacolin Woodland Resort. A witness who was staying at the resort, who viewed the airplane from his hotel room which was located on the northwest side of the runway reported that, after takeoff from runway 23, the airplane's landing gear retracted, and the airplane appeared to be departing the area; however, the airplane continued to turn as if entering the downwind leg of the traffic pattern. The landing gear extended, and the airplane began to descend. The airplane continued to descend in a turn consistent with a left base for runway 23; the witness then lost sight of the airplane behind terrain. Shortly after, he observed smoke. Another witness who was standing about 2,500 ft southeast of the runway saw the airplane pass overhead with the landing gear down. He stated that the airplane was "pretty low" and that the engine sounded normal. He saw the airplane bank to the left, and then he lost sight of it behind buildings; he then heard an impact and saw flames and smoke.

An onboard GPS recorded data for the accident flight. The recording began at 1415:57 near the airport parking area. The airplane subsequently taxied to the end of runway 23 for takeoff. Recorded GPS altitude at this time was about 1,975 ft. The takeoff roll began at 1420:18. At 1421:00, at a GPS altitude of 2,184 ft and about 2,500 ft from the departure end of the runway, the airplane began a left, climbing turn. The turn continued, and the airplane reached a maximum recorded altitude of 2,457 ft at 1421:36. At this time, its position was consistent with a left downwind for runway 23. The airplane descended as it continued the downwind leg, then began a left turn about 1422. Shortly thereafter, the airplane descended through 2,150 ft at 69 knots groundspeed. The last recorded data point was at 1422:22.

Figure 1. Plotted GPS Data – Complete Accident Flight.

Figure 2. Plotted GPS Data – End of Accident Flight.

About 1423, landscaping personnel called the resort's security dispatch and reported the accident. Security personnel arrived to find the airplane fully engulfed in flames and one passenger laying outside of the airplane on the golf course.

The passenger, who was severely burned during the accident, had egressed from the airplane by himself and was pulled from the accident site by resort guests. He advised first responders that his father (who was flying the airplane) and his friend were onboard the airplane. He remembered taking off from the runway, the door opening and feeling wind, and then being surrounded by flames. He was transported to a burn center and succumbed to his injuries about 2 days later.

PILOT INFORMATION

According to Federal Aviation Administration (FAA), and pilot records, the pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane, and a commercial pilot certificate with ratings for helicopter and instrument helicopter. His most recent application for an FAA third-class medical certificate was dated February 22, 2014. The pilot had accrued about 3,261 total hours of flight experience, of which 2,663 hours were in the accident airplane make and model.

AIRCRAFT INFORMATION

According to FAA airworthiness records and airplane maintenance records, the airplane was manufactured in 1984. The airplane's most recent annual inspection was completed on November 11, 2015. At the time of the inspection, the airplane had accrued about 4,448.5 total hours of operation, and the engine had accrued about 1,158.8 total hours of operation since major overhaul.

METEOROLOGICAL INFORMATION

The 1435 reported weather at Garrett County Airport (2G4), Oakland, Maryland, located 17 nautical miles southeast of the accident site, included wind from 250° at 11 knots gusting to 19 knots, 10 miles visibility, broken clouds at 1,300 ft, temperature 11°C, dew point 8°C, and an altimeter setting of 29.95 inches of mercury.

AIRPORT INFORMATION

PA88 was located about 1 mile east of Farmington, Pennsylvania. It was classified by the FAA as a privately owned, private-use airport. The airport elevation was 2,010 ft above mean sea level and the asphalt runway was configured in a 5/23 orientation. The runway measured 3,980 ft long by 49 ft wide. The runway 23 threshold was displaced 935 ft due to trees off the approach end of the runway. The runway was equipped with medium intensity runway edge lights, and a precision approach path indicator system which, at the time of the accident, was disabled.

FLIGHT RECORDERS

The accident airplane was equipped with a handheld Garmin GPSMAP 39x/49x series GPS.

The unit had suffered extreme thermal damage, but an internal examination revealed the non-volatile memory chip was intact, and data from the accident flight was extracted.




WRECKAGE AND IMPACT INFORMATION

The airplane came to rest in a heavily wooded area located next to a golf course.

Examination of the accident site revealed that the airplane had broken apart after striking trees in a left-wing-down, nose-low attitude. During the impact sequence, the main cabin portion of the airplane traveled about 152 ft before impacting the forest floor and coming to rest, facing the opposite direction of travel, with the aft fuselage and empennage lying behind it in an inverted position. The engine, left outboard wing, right wing flap, right main landing gear, and engine cowlings were all separated from their mounting positions and were strewn throughout the accident site. Further examination also revealed the presence of propeller strikes on broken tree branches and tree trunks that littered the ground, along with areas of burned underbrush and fire-damaged trees.

Examination of the wreckage revealed that the landing gear was in the down position, and all major portions of the airplane's structure were present at the accident site. No evidence of any preimpact failure of the airplane structure was discovered.

Examination of the flight control system revealed no evidence of any preimpact failure or malfunction, and flight control continuity was established from the flight control surfaces to the rudder pedals and control wheels through breaks in the system consistent with overstress failure.

Examination of the fuel system revealed that all four fuel caps were closed and locked, and the fuel selector valve was in the left main tank position.

Examination of the propeller and engine also revealed no evidence of any preimpact failure or malfunction that would have precluded normal operation. The propeller remained attached to the propeller flange and exhibited a circumferential fracture just aft of the propeller flange. All three blades exhibited S-bending, twisting, and chordwise scratching. Oil was present in the rocker boxes and oil sump, and the oil filter was absent of debris. Crankshaft and valve train continuity was confirmed, and compression and suction were observed on all six cylinders.

Examination of the interior of the cylinders with a lighted borescope did not reveal evidence of any preimpact damage to the piston domes, cylinder walls, or valves. Both magnetos were functional and produced spark at all towers.

Examination of the remains of the utility doors, which were located on the aft right side of the fuselage, and the forward cabin door, which was located on the forward right side of the fuselage, revealed that most of the door structures had been burned away. Further examination revealed that the locking mechanisms were present and did not show any evidence of malfunction or failure.

Examination of the forward cabin door revealed that the upper latching mechanism (hook) was not fully extended, and the slot in the upper fuselage frame that the hook engaged when the door was closed showed no evidence of tear-outs. Further examination also revealed that the door handle mechanism was not fully in the locked position; the lower aft latch pin, which rode in a guide inside the lower aft portion of the forward cabin door and engaged a receptacle in the lower door sill, was missing.

MEDICAL AND PATHOLOGICAL INFORMATION

According to FAA airman medical records, during his last medical examination, the pilot reported that he had no chronic medical conditions and was on no medications.

According to the report of the autopsy performed by Cyril H. Wecht and Pathology Associates, Inc., Pittsburgh, Pennsylvania, the cause of death was multiple blunt force injuries and the manner of death was accident. The autopsy identified minimal coronary artery disease with about 10-15% stenosis. The heart weight was not provided, but the right ventricular wall was described as 0.4-cm thick, the left ventricular wall as 1.5-cm thick, and the septum as 1.3-cm thick. Average for these thicknesses is 0.3 cm, 1.23 cm, and 1.23 cm, respectively. The remainder of the examination was unremarkable.

Toxicology testing performed at the request of the medical examiner by NMS Labs identified caffeine and 0.310 ug/ml of amphetamine in the pilot's blood.

Toxicology testing performed by the FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, identified amphetamine at 0.347 ug/ml in blood and 1.828 ug/ml in urine, as well as phenylpropanolamine in urine, but not in blood.

Amphetamine is a Schedule-II controlled substance that stimulates the central nervous system. It is available by prescription for the treatment of attention deficit disorder and narcolepsy. It carries a boxed warning about its potential for abuse and has warnings about an increased risk of sudden death and the potential for mental health and behavioral changes. Commonly marketed names include Adderall, Dexedrine, and Vyvanse. After a single 30 mg oral dose, early blood levels averaged 0.111 ug/ml and average blood levels in adults using the long acting prescription orally for a week were about 0.065 ug/ml. Generally, levels above 0.2 are the result of misusing amphetamine to maximize its psychoactive effects.

Amphetamine is also prepared and used as a street drug, often by snorting, inhaling, or injecting. Street preparations may begin with phenylpropanolamine, which may then contaminate the final product.

In the early phase, amphetamine misusers may experience a combination of euphoria, excitation, exhilaration, rapid flight of ideas, increased libido, rapid speech, motor restlessness, hallucinations, delusions, psychosis, insomnia, reduced fatigue or drowsiness, increased alertness, a heightened sense of well-being, stereotypes behavior, feelings of increased physical strength, and poor impulse control. Heart rate, blood pressure, and respiratory rate increase, and they may have palpitations, dry mouth, abdominal cramps, twitching, dilated pupils, faster reaction times, and increased strength. As the initial effects wear off, users commonly experience dysphoria, restlessness, agitation, and nervousness; they may experience paranoia, violence, aggression, a lack of coordination, delusions, psychosis, and drug craving.

Phenylpropanolamine is a sympathomimetic also in the amphetamine class that was once available in over-the-counter preparations for treating colds. However, it also increases heart rate and blood pressure, and its availability in the United States was discontinued in 2000. It remains available as a veterinary medicine.

ADDITIONAL INFORMATION

Materials Laboratory Examination

On May 4, 2016, the latching mechanism for the door of the airplane was examined in the NTSB Materials Laboratory. Deposits were observed on the external surfaces of the latching mechanism that were consistent with soot and other combustion products. Using a 5x to 50x stereo-zoom microscope, the fracture surfaces were examined. The fracture surface features were consistent with overstress related to incipient melting.

Pilot's Operating Handbook - Forward Cabin Door

The airplane's pilot's operating handbook (POH) stated that, when closed, the spring-loaded outside cabin door handle would fit into a recess to create a flat, aerodynamically clean surface. It could be locked from the outside with a key to secure the airplane.

The door could be opened from the outside by lifting the handle out of the recess and pulling until the door opened.

When closing the door from the inside of the airplane, the door handle was moved to the open position. In this position, the latch handle would be free to move about 1 inch in either direction before engagement of the locking mechanism. The door could then be grasped and firmly pulled closed, and the handle could then be fully rotated counterclockwise into the locked position. When the door was properly locked, the door latch handle would be free to move about 1 inch in either direction.

The POH noted that, when checking the door latch handle, "do not move it far enough to engage the doorlatch release mechanism." The POH also advised to press firmly at the top rear corner of the door and that, if any movement of the door was detected, to completely open the door, and close it again by following the instructions.

When exiting the airplane, the door could be opened from the inside by depressing the lock button, and rotating the handle clockwise.

The "BEFORE TAKEOFF" checklist contained in the POH included the item, "Doors and Windows – SECURE."

According to the POH, if the cabin door was not properly latched, it could unlatch in flight. This could occur during or just after takeoff. The door would trail open approximately 3 inches and result in a reduced rate of climb, but the flight characteristics of the airplane would otherwise not be affected. The procedure for an unlatched door in flight was to "Return to the field in a normal manner."

Beechcraft Mandatory Service Bulletin

In 1993, Beechcraft had received reports of the third latch pin (lower aft latch pin) on the cabin door retracting in flight due to misrigging and/or vibration. When the latch pin retracted, it would force the entire door latching mechanism to reverse, allowing the cabin door to open.

As a result, in September 1993, Beechcraft released Mandatory Service Bulletin No. 2457, which required that Kit 36-4007 be installed to modify the cabin door by adding a third latch pin overcenter mechanism, modify the bellcrank assembly for the third latch pin, and replace the original third latch pin guide assembly with a redesigned one to reduce the possibility of a cabin door opening in flight.

Comparison of the accident airplane's internal door locking mechanism to an exemplar internal door locking mechanism revealed that the door had not been modified in accordance with the mandatory service bulletin. Review of the airplane maintenance records also did not indicate that the mandatory service bulletin had been accomplished.

The pilot's spouse advised that they had the "door light" come on a few times before the accident, and that the door was hard to latch.

Review of the POH indicated that the annunciator panel in the airplane contained three annunciators placarded "LOW BUS VOLTS", "START", and "AFT DOOR." No indication of an annunciator being mounted in the panel for the forward cabin door was discovered.

Air Speed Information

Review of the GPS data showed that the airplane's groundspeed dropped to 69 knots prior to its rapid descent. Calculations using the wind vector solutions function of an E6-B flight computer indicated that the true airspeed of the airplane at that point, would have been about 79 knots, which was below the published stall speed in the Beechcraft Bonanza Pilot's Operating Handbook (POH) for banked turns in excess of about 45°. 

Pilot Information

Certificate: Commercial; Private
Age: 68, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Helicopter
Restraint Used: Unknown
Instrument Rating(s): Airplane; Helicopter
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 02/22/2014
Occupational Pilot: No
Last Flight Review or Equivalent: 11/01/2014
Flight Time: 3261 hours (Total, all aircraft), 2663 hours (Total, this make and model) 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: BEECH
Registration: N72054
Model/Series: A36 UNDESIGNATED
Aircraft Category: Airplane
Year of Manufacture: 1984
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: E-2181
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 11/11/2015, Annual
Certified Max Gross Wt.: 3651 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 4448.5 Hours as of last inspection
Engine Manufacturer: Continental
ELT: C91  installed, not activated
Engine Model/Series: IO-550-B78
Registered Owner: On file
Rated Power: 300 hp
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: 2G4, 2933 ft msl
Observation Time: 1425 EST
Distance from Accident Site: 17 Nautical Miles
Direction from Accident Site: 135°
Lowest Cloud Condition:
Temperature/Dew Point: 11°C / 8°C
Lowest Ceiling: Broken / 1300 ft agl
Visibility:  10 Miles
Wind Speed/Gusts, Direction: 11 knots/ 19 knots, 250°
Visibility (RVR):
Altimeter Setting: 29.95 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Farmington, PA (PA88)
Type of Flight Plan Filed: IFR
Destination: GAITHERSBURG, MD (GAI)
Type of Clearance:
Departure Time: 1420 EST
Type of Airspace: Class G 

Airport Information

Airport: Nemacolin Airport (PA88)
Runway Surface Type: Asphalt
Airport Elevation: 2010 ft
Runway Surface Condition: Dry
Runway Used: 23
IFR Approach: None
Runway Length/Width: 3980 ft / 49 ft
VFR Approach/Landing: Precautionary Landing; Traffic Pattern 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 2 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude: 39.813889, -79.535278
















































NTSB Identification: ERA16FA064 
14 CFR Part 91: General Aviation
Accident occurred Friday, December 11, 2015 in Farmington, PA
Aircraft: BEECH A36, registration: N72054
Injuries: 3 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. 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.

On December 11, 2015, at approximately 1420 eastern daylight time, a Beech A36; N72054, was Destroyed when it impacted trees and terrain after a loss of control during a return to the airport, after takeoff from Nemacolin Airport (PA88), Farmington, Pennsylvania, The certificated private pilot was fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the Title 14 Code of Federal Regulations Part 91 personal flight, destined for Montgomery County Airport (GAI), Gaithersburg, Maryland.

According to witness statements, after departure from runway 23 at PA88, the landing gear on the airplane was observed to retract, and the airplane "made a sudden turn like it was trying to turn around." The landing gear then extended into the down position. The airplane was next observed turning onto a close in, left base leg for runway 23 "pretty low" to the ground, about 800 yards from the Nemacolin Woodlands Resort Outdoor Animal Exhibits Area, and then was lost from sight as it passed behind the resort's Panoramic Pavilion. Moments later the sound of the airplane impacting trees and then the ground was heard, and a "fireball" and smoke was observed to rise into the air.

The airplane came to rest in a heavily wooded area located next to the 11th fairway of the resort's Links Golf Course and was subject to a postcrash fire.

Examination of the accident site revealed that the airplane had broken apart after striking trees in a left wing down, nose low attitude. During the impact sequence, the main cabin then traveled approximately 152 feet before impacting the forest floor and coming to rest, facing the opposite direction of travel, with the aft fuselage and empennage lying behind it in an inverted position. The engine, left outboard wing, right wing flap, right main landing gear, and engine cowlings, were all separated from their mounting positions and were strewn throughout the accident site. Further examination also revealed the presence of propeller strikes on broken off tree branches and tree trunks that littered the ground, along with areas of burned underbrush and fire damaged trees.

Examination of the wreckage revealed that the landing gear was in the down position, and all major portions of the airplane's structure were present at the accident site. No evidence of any preimpact failure of the airplane structure was discovered.

Examination of the flight control system revealed no evidence of any preimpact failure or malfunction and flight control continuity was able to be established from the flight control surfaces, to the breaks in the system, and from the breaks in the system, to the rudder pedals and control wheels.

Examination of the fuel system revealed that all four fuel caps were closed and locked, and the fuel selector valve was in the left main tank position.

Examination of the propeller and engine also revealed no evidence of any preimpact failure or malfunction that would have precluded normal operation. The propeller remained attached to the propeller flange and a circumferential fracture just aft of the propeller flange was present. All three blades exhibited S-bending, twisting, and chord wise scratching. Oil was present in the rocker boxes and oil sump, and the oil filter was absent of debris. Crankshaft and valve train continuity was confirmed and compression and suction was observed on all six cylinders. Examination of the interior of the cylinders with a lighted borescope did not reveal evidence of any preimpact damage to the piston domes, cylinder walls, or valves. Both magnetos were functional, and produced spark at all towers.

Examination of the remains of the utility doors which were located on the aft right side of the fuselage and the forward cabin door which was located on the forward right side of the fuselage revealed that the majority of the doors structures had been burned away. Further examination revealed however, that the locking mechanisms were made of steel, were present.

Examination of the utility doors locking mechanism did not show any evidence of malfunction or failure.

Examination of the forward cabin door revealed that the upper latching mechanism (hook) was not fully extended, and the slot in the upper fuselage frame that the hook engaged when the door was closed, showed no evidence of tear-outs. Further examination also revealed that the door handle mechanism was not fully in the locked position. The bayonet which engaged the lower door sill was not recovered.

According to Federal Aviation Administration (FAA) and pilot records, the pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane, and a commercial pilot certificate with ratings for helicopter and instrument helicopter. His most recent application for a FAA third-class medical certificate was dated February 22, 2014. The pilot reported that he had accrued approximately 3,261 total hours of flight experience, of which 2,663 hours were in the accident airplane make and model.

According to FAA and airplane maintenance records, the airplane was manufactured in 1984. The airplane's most recent annual inspection was completed on November 11, 2015. At the time of the inspection, the airplane had accrued approximately 4,448.5 total hours of operation, and the engine had accrued approximately 1,158.8 total hours of operation since major overhaul.

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