Sunday, May 12, 2019

Visual Flight Rules Encounter with Instrument Meteorological Conditions: Beech Bonanza V35A, N7019N, fatal accident occurred March 25, 2018 in Hydro, Caddo County, Oklahoma


Walter "Rick" Mullaney
Rick was an oil and gas landman, commercial pilot, ham radio operator, and managed the El Reno Regional Airport for 25 years. He was a member of the Masonic Lodge and the National Rifle Association.


Cesar Gomez 
1990-2018

Cesar was a quarter horse jockey. According to Daily Racing Form LLC, Cesar won the Grade 1 All-American Gold Cup at Ruidoso Downs in 2015. He won the first race of his career in March 2014. His mounts pocketed more than $5.6 million in purses, according to Daily Racing Form LLC. 

 Cesar Gomez won 267 races. 


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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Oklahoma City, Oklahoma
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 
 
http://registry.faa.gov/N7019N



Walter "Rick" Mullaney

Location: Hydro, OK
Accident Number: ERA18FA114
Date & Time: 03/25/2018, 2137 CDT
Registration: N7019N
Aircraft: BEECH V35
Aircraft Damage: Destroyed
Defining Event: VFR encounter with IMC
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On March 25, 2018, about 2137 central daylight time, a Beech V35A, N7019N, was destroyed when it impacted terrain near Hydro, Oklahoma. The commercial pilot and passenger were fatally injured. The airplane was owned by the pilot who was operating it as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. Night instrument meteorological conditions prevailed, and no flight plan was filed for the flight, which departed from Odessa Airport-Schlemeyer Field (ODO), Odessa, Texas, about 1947, and was destined for El Reno Regional Airport (RQO), El Reno, Oklahoma.

The pilot and passenger departed RQO earlier in the day and arrived at ODO about 1345. A line technician at the ODO fixed-base operator (FBO) reported that the passenger left the airport shortly after the airplane arrived and the pilot remained in the terminal. The FBO technician reported that the pilot asked that weather radar and satellite information be displayed on a large monitor throughout the afternoon, as the pilot stated to him that he was "concerned with the clouds."

Review of an audio recording from Leidos Flight Service in Austin, Texas, revealed that the pilot called for a weather briefing at 1806. The pilot informed the flight service specialist that he was planning a visual flight rules (VFR) flight from ODO to RQO in about 30 minutes and it would be about a 2.5-hour flight. During the 11-minute call, the flight service specialist provided the pilot with numerous weather and flight information details.

The flight service specialist informed the pilot that multiple AIRMETs affected his route of flight. The specialist stated that one AIRMET was for "IFR [instrument flight rules] right at your destination," developing between 1900-2200, "shortly after you depart Odessa." The pilot stated, "I don't see that being a problem right now, I can see things are changing out here. Things look good v-f-r at Odessa." The specialist responded, "yeah, this isn't a problem about Odessa, it's about your destination. Your first part of your route isn't the problem, it might be that last part. Can you go i-f-r if you need to?" The pilot responded, "yeah, I can if I need to." The specialist and pilot continued the briefing for another 7 minutes; an audio recording of the entire call is available in the public docket.

Review of air traffic control audio provided by the Federal Aviation Administration (FAA) revealed that the pilot requested VFR flight following services upon departure from ODO, and radio communications were uneventful for about the first 1 hour 40 minutes of the flight. About 2120, the pilot checked in with the Oklahoma City Terminal Radar Approach Control Facility (OKC approach) and was provided with the current altimeter setting.

About 2125, the OKC approach controller asked the pilot if he had RQO in sight. The pilot stated that he did not and informed the controller that he was trying to "get down underneath it [clouds]" and asked for the reported weather at Oklahoma City Airport (OKC). The controller informed him that OKC reported a ceiling of 1,100 ft agl, which the pilot acknowledged. 

About 2126, the controller informed the pilot that Hinton Municipal Airport (2O8), Hinton, Oklahoma, was to the west about 5 miles, and asked if he would like to try that airport. The pilot acknowledged the suggestion and began to navigate toward 2O8.

About 2128, the controller informed the pilot that Hinton was at his 12 o'clock and 3 miles. The pilot did not respond. The controller attempted to contact the pilot two additional times, and on the third attempt, instructed the pilot to 'ident' the transponder. 

At 2128:56, the pilot responded, "I'm hearing you, I'm still trying to get out of these clouds here uh I'm uh headed over towards Hinton right now but I'm going to go back out to the west and see if I can get underneath [the clouds]."

About 2129, the OKC controller instructed the pilot to contact the Fort Worth Air Route Traffic Control Center (ZFW center) controller and informed the pilot that he was actually in ZFW's airspace at that time. The pilot did not respond. For the next 1.5 minutes, the OKC controller attempted to contact the pilot three additional times and, on the fourth attempt, he instructed the pilot to click his microphone twice if he could hear the transmission. The pilot did not respond, and no microphone clicks were heard on the audio recording.

About 2131, the pilot transmitted, "…uh I'm still uh trudging out to the west here I'm still trying to get back out of it uh could you give me the el reno [weather]." The OKC controller asked the pilot how he heard the transmission. The pilot did not respond. The ZFW controller attempted to contact the pilot, but the pilot did not respond. The OKC controller attempted to contact the pilot again, and the pilot told the controller to go ahead. The OKC controller informed the pilot that he could not tell if he could hear him or not.

About 2132, the pilot responded to the OKC controller, "okay I'm I'm uh I'm trying to uh I'm still trying to get out of this I I see it's clear above I'm just going to climb back up here." Seventeen seconds later, the OKC controller informed the pilot that the weather at RQO included 7 miles of visibility with an 800-ft overcast ceiling. The pilot responded, "…okay that explains it alright very good." The OKC controller told the pilot to contact ZFW center and advised him that ZFW center had radar contact on the airplane and that they would work with him. The pilot acknowledged.

About 2133, the pilot transmitted on the OKC approach frequency, "…Fort Worth center … we're uh back v f r on top again." The OKC controller advised the pilot that he was still transmitting on OKC approach control frequency. The pilot acknowledged and switched to the ZFW center frequency. 

At 2133:19, the pilot contacted the ZFW controller and reported that he was at 3,500 ft. The ZFW controller asked the pilot his intentions, to which the pilot responded, "okay my intentions are now that I've got myself out of the clouds, I'm back up on top here I'm going to try to go out to the west and get and slide in underneath it." The controller asked where he was flying to the west and where the pilot wanted to get back to. The pilot responded, "okay I'll try and go out towards Hinton Oklahoma and uh I'll try and get on the outskirts of this overcast and try to go underneath it to go to uh el reno." The controller acknowledged the transmission.

About 2138, the ZFW controller informed the pilot that radar contact was lost and asked the pilot to say his altitude. The pilot did not respond. The controller attempted to contact the pilot three additional times, but there were no further communications received from the pilot.

Review of radar data provided by the FAA revealed that the airplane was established on a northeasterly course toward RQO when, about 2125 and 8 miles from the airport, the airplane turned north, then west toward the town of Hinton, Oklahoma. The airplane continued flying west, passing Hinton Airport (2O8) about 1 mile south at 2,700 ft mean sea level (msl), and then flew southwest. At 2134, the airplane was about 7 miles south of Hydro, Oklahoma, flying southwest at 3,850 ft msl. Figure 1 shows the airplane's flight path and change of course.

Figure 1: Overview of Radar Flight Path

The radar track showed the airplane subsequently enter two left, descending, 360° spiral turns, leveling off about 2,200 ft msl. The airplane then flew north for about 20 seconds; the last radar target, at 2137, showed the airplane flying at 2,125 ft msl on a heading of 033° at 157 knots groundspeed. The final radar target was about 1/4 mile southwest of the accident site. Figure 2 depicts the spiral flight path.


Figure 2: Closer View of Final Few Minutes of Radar Flight Path

A witness, who was traveling southbound in his car on a road about 1/2 mile west of the accident site about the time of the accident, saw a "steady red light" and a "steady white light" travel over his car. He continued watching the lights out of his driver's side window for about 10 to 15 seconds, looking eastward, as the lights continued to get lower in his field of view; suddenly, he observed a bright "yellow glow" ignite. He attempted to drive to where he observed the bright yellow glow, but the light extinguished before he could reach the area.

PERSONNEL INFORMATION

According to FAA airman records, the pilot held a commercial pilot certificate with ratings for airplane single- and multi-engine land and instrument airplane. The pilot was issued an FAA second-class medical certificate on January 18, 2018. At that time, the pilot reported civil flight experience that included 4,500 total hours and 2 hours in the previous 6 months.

A review of the pilot's logbook contained a record of flights between August 30, 1994 and March 23, 2011. The total recorded flight time accumulated in this logbook was 2,580.5 hours. The logbook showed that his most recent flight review endorsement was dated September 2, 2016.

The most recent instrument proficiency check was dated December 27, 2001.

Another logbook located in the wreckage contained flight entries starting in December 2, 2010 and ending on March 9, 2018. The entries were for flights specific to the accident airplane and contained numerous entries by the accident pilot, as well as entries from other pilots who had flown the airplane. The last logbook entry recorded by the accident pilot was on March 5, 2018. Reviewing the accident pilot's entries from February 27, 2016, through the last entry, he recorded a total time of 55.8 hours in the accident airplane. Within the previous 12 months, he recorded 8.3 hours. The accident pilot noted one-night landing on September 3, 2016, and two additional night landings on February 27, 2016. Additionally, within the remarks section, the accident pilot noted two instrument approaches for two separate flights in September 2017. There were no other remarks or entries regarding night landings or instrument approaches in the previous 12 months. No other personal logbooks containing more recent flights for the pilot were found.

AIRCRAFT INFORMATION

The airplane was a Beech V35A, a 5-seat, single-engine, low-wing airplane manufactured in 1967. It was powered by a Continental IO-520-BAcBB 285-horsepower engine. It was equipped with two 40-gallon fuel tanks. A review of the airplane's maintenance records revealed that the most recent annual and 100-hour inspection was performed on December 21, 2017 at an airframe time of 3,361.17, a tachometer time of 2,559.17, and 887.6 hours since major engine overhaul. The tachometer found in the debris field displayed 2,583.17 hours.

A fuel receipt from the FBO at ODO indicated that 25.3 gallons of 100LL aviation fuel was added to the airplane. A line technician reported that he filled the airplane to the highest visual fuel tabs per the pilot's request, which, according to the pilot's operating handbook, corresponds to 64 gallons of total fuel on board and at least 4 hours of fuel endurance.

METEOROLOGICAL INFORMATION

The weather conditions reported at 2135 at Thomas P. Stafford Airport (OJA), Weatherford, Oklahoma, 7 miles northwest of the accident site, included an overcast cloud ceiling at 800 ft above ground level (agl), wind from 120° at 11 knots gusting to 18 knots, 7 statute miles visibility, temperature 17°C, and dew point 16°C. The OJA weather observation was the nearest available weather to 2O8.

At 2115, the OJA observation included scattered clouds at 1,000 and 1,300 ft agl, wind from 130° at 14 knots gusting to 20 knots, 7 statute miles visibility, temperature 17°C, and dew point 16°C.

The weather conditions at RQO, about 27 miles east of the accident site, at 2115, included an overcast cloud ceiling at 800 ft agl, wind from 130° at 18 knots, 7 statute miles visibility, temperature 17°C, dew point 16°C, and barometric pressure 29.80 inches of mercury.

At 2135, the RQO observation included an overcast cloud ceiling at 800 ft agl, wind from 140° at 19 knots gusting to 25 knots, 7 statute miles visibility, temperature 18°C, dew point 16°C, and barometric pressure 29.80 inches of mercury.

A review of nearby weather reporting stations revealed that two airports, each about 35 miles southwest of the accident location, reported VFR conditions around the time of the accident.

Clinton-Sherman Airport (CSM), Burns Flat, Oklahoma, reported clear skies and 9 statute miles visibility at 2053. At 2153, scattered clouds were reported at 1,200 ft agl, with a visibility of 8 statute miles. At 2253, clear skies and visibility of 8 statute miles were reported.

Hobart Regional Airport (HBR), Hobart, Oklahoma, reported clear skies and visibility of 9 statute miles at 2053. At 2153, clear skies and visibility of 10 statute miles were reported. At 2253, a clear ceiling and visibility of 10 statute miles were reported. Reference the Flight Path Overview and Surrounding Hourly Weather Reports in the public docket.

The Geostationary Operational Environmental Satellite (GOES)-16 infrared imagery at 2137 for the area immediately surrounding the accident location were between 12°C and -27°C, which corresponded to cloud top heights between 8,000 and 25,500 ft msl. In addition, satellite imagery identified that, at the time of the accident, low, warm clouds were in the accident region.

Astronomical data obtained from the United States Naval Observatory for the accident area indicated that the end of civil twilight was at 2016, and the phase of the moon indicated a waxing gibbous with 62% of the moon's visible disk illuminated. [A complete NTSB Weather Study is available in the public docket.]

The witness reported that it was windy at the time of the accident, and it was a darker than a normal night as "the moon was not visible." He reported that, other than a farmhouse light, there were no other cars that passed him near the time of the accident, the road was not lit, and the fields around the accident site were "pitch black."

WRECKAGE AND IMPACT INFORMATION

The main wreckage came to rest upright in a flat, open field on a magnetic heading of 060° at an elevation about 1,670 ft msl. The airplane sustained extensive impact damage and there was evidence of a small postimpact fire. The engine separated from the firewall and was located about 220 ft forward of the main wreckage.

All major components of the airplane were accounted for at the accident site and flight control continuity was established for all flight controls to the cockpit area. The landing gear selector and actuators were found in the retracted position. The flap handle and actuators were found in the retracted position. The fuel strainer screen and fuel strainer bowl were found clean. The fuel selector handle and valve were found selected to the right fuel tank.

The cockpit instrument panel, navigation, and communication instruments were impact damaged. The attitude indicator and heading indicator were found in the debris field. The heading indicator displayed a heading of 060°. Both gyroscope housings exhibited evidence of rotational scoring. The throttle lever and mixture control levers were found full forward and bent. The propeller control lever was found pulled out (aft).

The airplane was equipped with five seats. The two front seats were separated from the airframe and found in the debris field. One front seat lap belt was found buckled with its attach point stitching ripped on one side. The other front seat lap belt was found unbuckled with one of its attach points stitching ripped. The number 5 passenger seat was the only seat found attached to the airframe. The airplane was not equipped with shoulder harnesses.

The engine crankshaft was rotated by hand. Valve train continuity was established and all pistons operated normally. Each spark plug displayed varying degrees of impact damage; the top spark plugs were visually inspected and displayed normal operating and combustion signatures. The cylinders were inspected using a lighted borescope; the cylinder bore, piston faces, and valve heads displayed normal operating and combustion signatures.

The fuel manifold valve and fuel nozzles were examined and no debris was observed. Numerous engine accessories separated from the engine and were found in the debris field. Both magnetos separated from the engine and produced spark when rotated by an electric drill.

The vacuum pump remained attached to the engine and displayed impact damage signatures. The vacuum pump was removed; the shear coupling remained intact. The vacuum pump was disassembled and the rotor was impact damaged.

All three propeller blades had broken free from the propeller hub and displayed impact damage signatures. Each propeller blade displayed varying amounts of S-bending, blade polishing, leading edge gouging, and twisting deformation.

The postaccident examination of the airplane did not reveal any anomalies consistent with a preimpact failure or malfunction. A detailed airframe and engine examination report is in the public docket.

MEDICAL AND PATHOLOGICAL INFORMATION

The Office of the Chief Medical Examiner, Oklahoma City, Oklahoma, performed an autopsy of the pilot. The report stated that the probable cause of death was "multiple trauma due to light plane crash – pilot."

The FAA Forensic Sciences Laboratory conducted toxicological testing of specimens of the pilot. Testing was negative for volatiles and drugs.

ADDITIONAL INFORMATION

Spatial Disorientation

The FAA Civil Aeromedical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a loss of proper bearings or a state of mental confusion as to position, location, or movement relative to the position of the earth. Factors contributing to spatial disorientation include changes in acceleration, flight in instrument meteorological conditions (IMC), frequent transfer between visual meteorological conditions (VMC) and IMC, and unperceived changes in aircraft attitude.

The FAA's Airplane Flying Handbook (FAA-H-8083-3A) describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part:

The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation.

Night and Instrument Currency

According to excerpts from 14 CFR Part 61.57, Recent flight experience:

Pilot in command, (b) night takeoff and landing experience, in order to act as pilot in command of an aircraft carrying passengers during the period beginning 1 hour after sunset and ending 1 hour before sunrise, within the preceding 90 days the pilot must have made at least three takeoffs and three landings to a full stop during the period beginning 1 hour after sunset and ending 1 hour before sunrise.

In addition, part (d) states, Instrument proficiency check: a person who has failed to meet the instrument experience requirements of paragraph (c) of this section for more than six calendar months may reestablish instrument currency only by completing an instrument proficiency check.

Pilot Information

Certificate: Commercial
Age: 62, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 01/18/2018
Occupational Pilot: No
Last Flight Review or Equivalent: 09/02/2016
Flight Time:  (Estimated) 4500 hours (Total, all aircraft), 55.8 hours (Total, this make and model)

Aircraft and Owner/Operator Information

Aircraft Make: BEECH 
Registration: N7019N
Model/Series: V35 A
Aircraft Category: Airplane
Year of Manufacture: 1967 
Amateur Built: No
Airworthiness Certificate: Utility
Serial Number: D-8619
Landing Gear Type: Retractable - Tricycle
Seats: 5
Date/Type of Last Inspection: 12/21/2017, Annual
Certified Max Gross Wt.: 3400 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 3361.17 Hours as of last inspection
Engine Manufacturer: Continental
ELT: Installed, not activated
Engine Model/Series: IO-520-BAcBB
Registered Owner: ON TOP FLYING CO LLC
Rated Power: 285 hp
Operator: On file
Operating Certificate(s) Held:None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Night/Dark
Observation Facility, Elevation: KOJA, 1607 ft msl
Distance from Accident Site: 8 Nautical Miles
Observation Time: 2135 CDT
Direction from Accident Site: 315°
Lowest Cloud Condition:
Visibility:  7 Miles
Lowest Ceiling: Overcast / 800 ft agl
Visibility (RVR):
Wind Speed/Gusts: 11 knots / 18 knots
Turbulence Type Forecast/Actual: / None
Wind Direction: 120°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 29.77 inches Hg
Temperature/Dew Point: 17°C / 16°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: ODESSA, TX (ODO)
Type of Flight Plan Filed: None
Destination: EL RENO, OK (RQO)
Type of Clearance: VFR; VFR Flight Following
Departure Time: 1947 CDT
Type of Airspace: Class G 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 35.454444, -98.562778

2 comments:

Anonymous said...

Yikes another one

Anonymous said...

The rules are written in blood for a reason. If you don't do what is required of you, bad things happen sometimes. Based on the transcripts, the pilot got way behind the airplane and should have listened to the specialist regarding the weather and not made the flight OR at least diverted to an airport with better weather. Classic case of getthereitis.