Sunday, June 20, 2021

Loss of Control in Flight: Beechcraft A36 Bonanza, N6150X; fatal accident occurred June 20, 2019 in Elida, Allen County, Ohio

Steven Douglas Niemann

Tracey Hartnett

Aviation Accident Final Report - National Transportation Safety Board

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

Additional Participating Entities: 
Federal Aviation Administration / Flight Standards District Office; Columbus, Ohio
Textron Aviation; Wichita, Kansas
Continental Aerospace Technologies; Mobile, Alabama

Investigation Docket - National Transportation Safety Board:

Location: Elida, Ohio 
Accident Number: CEN19FA177
Date & Time: June 20, 2019, 16:12 Local
Registration: N6150X
Aircraft: Beech A36
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General aviation - Personal


The noninstrument-rated private pilot and passenger departed on the cross-county flight under visual flight rules (VFR) in visual meteorological conditions and proceeded on course at an altitude of about 9,000 ft mean sea level (msl). As the flight progressed, the weather conditions deteriorated, and about halfway through the flight, the pilot appeared to deviate before resuming flight toward the destination and descended to about 2,000 ft msl over about 30 minutes. Within 20 miles of the accident site, the pilot executed multiple course changes, including two 360° turns. The airplane then entered a right turn from a southeasterly course to a southwesterly course, and about 1 minute before the accident, the airplane re-entered the right turn, which progressed into a right graveyard spiral that continued until impact.

Weather observations and satellite imagery indicated that instrument meteorological conditions (IMC) prevailed in the vicinity of where the pilot began making the multiple course changes and at the accident site. It is likely that the pilot encountered rain, and possibly heavy rain, during the final portion of the flight. There was no record of the pilot obtaining a preflight weather briefing from an official source.

Examinations of the airframe and engine did not reveal any anomalies consistent with a preimpact failure or malfunction.

Toxicology testing of the pilot revealed the presence of carboxy-delta-9-tetrahydrocannabinol (THC), an inactive metabolite of THC. The low-level presence of the inactive THC metabolite suggests that the pilot was not under the influence of THC at the time of the flight, and therefore, it is unlikely that any effects from the pilot's prior use contributed to the accident. The testing also revealed the presence of diphenhydramine; however, it did not provide a blood level. Therefore, whether the pilot might have been impaired from the diphenhydramine at the time of the accident or whether his prior use contributed to the accident could not be determined.

The restricted visibility conditions present in the area were conducive to the development of spatial disorientation, and the airplane's maneuvering and spiraling descent are consistent with the known effects of spatial disorientation. It is likely that the pilot experienced spatial disorientation during an encounter with instrument meteorological conditions, which resulted in a loss of control.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The noninstrument-rated pilot's decision to continue visual flight rules flight into an area of instrument meteorological conditions, which resulted in a loss of control due to spatial disorientation. Contributing was the pilot not obtaining a weather briefing prior to the flight.


Personnel issues Spatial disorientation - Pilot
Personnel issues Aircraft control - Pilot
Personnel issues Decision making/judgment - Pilot
Personnel issues Qualification/certification - Pilot
Personnel issues Weather planning - Pilot
Environmental issues Below VFR minima - Decision related to condition
Environmental issues Below VFR minima - Effect on operation

Factual Information

History of Flight

Enroute VFR encounter with IMC
Enroute Loss of control in flight (Defining event)
Uncontrolled descent Collision with terr/obj (non-CFIT)

On June 20, 2019, at 1612 eastern daylight time, a Beech A36 airplane, N6150X, was destroyed when it was involved in an accident near Elida, Ohio. The private pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

The pilot departed Maquoketa Municipal Airport (OQW), Maquoketa, Iowa, about 1255 and was destined for Toledo Executive Airport (TDZ), Toledo, Ohio. Visual meteorological conditions prevailed near OQW about the time of departure and weather information indicated that the initial portion of the flight was conducted in visual meteorological conditions. However, weather conditions deteriorated as the flight progressed. Automatic Dependent Surveillance – Broadcast (ADS-B position data indicated that the airplane climbed to an altitude of about 9,000 ft mean sea level (msl) and proceeded southeast before turning east and transitioning south of the Chicago, Illinois, metropolitan area while maintaining 9,000 ft msl. The pilot subsequently returned to a southeasterly course until nearing Logansport, Indiana, when he again took up an easterly course and transitioned south of Ft. Wayne, Indiana. During this time, the airplane began a gradual descent over the next 30 minutes eventually leveling at 2,000 ft. msl. The track data depicted multiple course changes, including two 360° turns within 20 miles of the accident site. About 1610:45, the airplane entered a right turn, changing its course from southeasterly to southwesterly over about 30 seconds. About 1611:15, the airplane entered a second right turn, which transitioned into a right descending spiral until the final data point at 1612:14. At that time, the airplane was located about 1/4 mile north-northwest of the accident site at an altitude of 2,110 ft msl, which was about 1,330 ft above ground level (agl).

At 1647, a local resident saw the wreckage in an agricultural field and contacted authorities. There were no known witnesses to the accident.

Pilot Information

Certificate: Private 
Age: 65, Male
Airplane Rating(s): Single-engine land; Single-engine sea
Seat Occupied: Left
Other Aircraft Rating(s): None 
Restraint Used: 3-point
Instrument Rating(s): None 
Second Pilot Present: No
Instructor Rating(s): None 
Toxicology Performed: Yes
Medical Certification: BasicMed
Last FAA Medical Exam: May 29, 2017
Occupational Pilot: No
Last Flight Review or Equivalent: March 11, 2019
Flight Time: 1640 hours (Total, all aircraft)

Federal Aviation Administration (FAA) records indicated that the pilot did not hold, nor had he ever applied for an instrument rating. His application for the addition of a seaplane rating, dated March 15, 2017, indicated a total instrument flight time of 1.0 hours. The pilot's logbook was not available during the investigation; however, a copy of the pilot's flight review endorsement was provided after the initial factual report was released.. The investigation was not able to determine if the pilot had completed any instrument training after issuance of his private pilot certificate.

The pilot did not hold a current medical certificate; however, he had applied for BasicMed. He completed the BasicMed course on May 29, 2017, and his Comprehensive Medical Examination Checklist was completed on May 15, 2017. The pilot was medically eligible to fly as long he had a valid driver's license and was in compliance with 14 Code of Federal Regulations Part 68, Requirements for operating small aircraft without a medical certificate.

Aircraft and Owner/Operator Information

Aircraft Make: Beech
Registration: N6150X
Model/Series: A36 
Aircraft Category: Airplane
Year of Manufacture: 1981 
Amateur Built: No
Airworthiness Certificate: Utility
Serial Number: E-1961
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: June 14, 2019 Annual 
Certified Max Gross Wt.: 3651 lbs
Time Since Last Inspection: 
Engines: 1 Reciprocating
Airframe Total Time: 2801.1 Hrs as of last inspection
Engine Manufacturer: Continental
ELT: C91 installed, activated, did not aid in locating accident
Engine Model/Series: IO-550-B
Registered Owner: 
Rated Power: 300 Horsepower
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument (IMC)
Condition of Light: Day
Observation Facility, Elevation: AOH,975 ft msl
Distance from Accident Site: 10 Nautical Miles
Observation Time: 15:53 Local 
Direction from Accident Site: 145°
Lowest Cloud Condition: 
Visibility: 6 miles
Lowest Ceiling: Overcast / 800 ft AGL
Visibility (RVR):
Wind Speed/Gusts: 18 knots / 28 knots 
Turbulence Type Forecast/Actual:  /
Wind Direction: 250° 
Turbulence Severity Forecast/Actual:  /
Altimeter Setting: 29.57 inches Hg
Temperature/Dew Point: 19°C / 18°C
Precipitation and Obscuration: N/A - None - Mist
Departure Point: Maquoketa, IA (OQW) 
Type of Flight Plan Filed: None
Destination: Toledo, OH (TDZ) 
Type of Clearance: None
Departure Time: 12:55 Local
Type of Airspace: Class G

There was no record that the pilot obtained an official preflight weather briefing or that he had requested any weather information during the flight.

At 1555, conditions at the Putnam County Airport (OWX), Ottawa, Ohio, about 14 miles north-northeast of the accident location, included scattered clouds at 600 ft agl, broken clouds at 1,700 ft agl, and 5 miles visibility. At 1555, conditions at the Van Wert County Airport (VNW), Van Wert, Ohio, about 20 miles west of the accident site, included broken clouds at 500 ft agl, overcast clouds at 1,000 ft agl, and 2 miles visibility in rain.

Satellite imagery depicted cloudy conditions across the region. Overcast clouds prevailed near the accident site, with cloud tops above 10,000 ft msl and localized build-ups to about 30,000 ft msl. The presence of any intervening cloud layers was not known. Radar imagery depicted light to heavy precipitation across the region. The accident occurred as the airplane approached an area of moderate to heavy perception.

An AIRMET warning of instrument conditions was in effect at the time of the accident.

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal 
Aircraft Fire: None
Ground Injuries: N/A 
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 40.846389,-84.158332

The accident site was located in an agricultural field. The debris field extended about 117 ft north northeast of the main wreckage. The airplane came to rest upright on a northwest heading. The engine was separated from the airframe and located in position immediately adjacent to the fuselage. The left wing was partially separated from the fuselage, bent forward 90o, and located resting against the forward fuselage. The right wing and empennage remained attached to the fuselage. The control surfaces remained attached to the airframe.

Examination of the airframe and engine did not reveal any anomalies consistent with a preimpact failure or malfunction. A detailed summary of the accident site and the postaccident examinations is available in the public docket.

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 VMC and IMC, and unperceived changes in aircraft attitude.

The FAA Airplane Flying Handbook 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.

The FAA Pilot's Handbook of Aeronautical Knowledge provides information concerning spatial disorientation and vestibular illusions. Regarding the "graveyard spiral" illusion, it states:

A pilot in a prolonged coordinated, constant-rate turn may experience the illusion of not turning. During recovery to level flight, the pilot will then experience the sensation of turning in the opposite direction causing the disoriented pilot to return the aircraft to its original turn. Because an aircraft tends to lose altitude in turns unless the pilot compensates for the loss of lift, the pilot may notice a loss of altitude.

The absence of any sensation of turning created the illusion of being in a level descent. The pilot may pull back on the control sin an attempt to climb or stop the descent. This action tightens the spiral and increase the loss of altitude; this illusion is referred to as a "graveyard spiral." This may lead to a loss of aircraft control.

Medical and Pathological Information

An autopsy of the pilot conducted by the Lucas County Coroner's Office, Toledo, Ohio, attributed his death to multiple blunt traumatic injuries sustained in the accident. Toxicology testing was performed by the FAA Forensic Sciences Laboratory. The testing detected 2.2 (ng/mL, ng-g) carboxy-delta-9-tetrahydrocannabinol (THC) in cavity blood and 16.5 (ng/mL, ng/g) in liver tissue; diphenhydramine in muscle and liver tissue; and rosuvastatin in muscle and liver tissue. No ethanol and no carboxyhemoglobin were detected in cavity blood.

Carboxy-delta-9-THC is an inactive metabolite of THC. Although THC itself is the primary psychoactive component in marijuana and is considered to be impairing, the inactive metabolite, carboxy-delta-9-THC, is not considered to be impairing. Diphenhydramine is an antihistamine available as an over-the-counter medication commonly used to treat allergy symptoms and as a sleep aid. Due to
its sedating effects, it is considered to be impairing. Rosuvastatin is a cholesterol lowering medication available by prescription and is not considered to be impairing.

Preventing Similar Accidents

Reduced Visual References Require Vigilance

About two-thirds of general aviation accidents that occur in reduced visibility weather conditions are fatal. The accidents can involve pilot spatial disorientation or controlled flight into terrain. Even in visual weather conditions, flights at night over areas with limited ground lighting (which provides few visual ground references) can be challenging.

Preflight weather briefings are critical to safe flight. In-flight, weather information can also help pilots make decisions, as can in-cockpit weather equipment that can supplement official information. Incockpit equipment requires an understanding of the features and limitations.

We often see pilots who decide to turn back after they have already encountered weather; that is too late. Pilot's shouldn't allow a situation to become dangerous before deciding to act. Additionally, air traffic controllers are there to help; be honest with them about your situation and ask for help.

Even when flying at night, visual weather conditions can also be challenging. Remote areas with limited ground lighting provide limited visual reference cues for pilots, which can be disorienting or render rising terrain visually imperceptible. Topographic references can help pilots become more familiar with the terrain. The use of instruments, if pilots are proficient, can also help pilots navigate these challenging areas.

See for additional resources.

The NTSB presents this information to prevent recurrence of similar accidents. Note that this should not be considered guidance from the regulator, nor does this supersede existing FAA Regulations (FARs). 


  1. how do u get killed in an open field ?

    1. As I've heard an old instructor say, "a J3 Cub is just barely fast enough to kill ya".

    2. descending in a the time you come out of the clouds and see what's're out of time. And your passenger is screaming.

    3. The same way you can get killed in a closed one.

    4. One way is to enter IMC without an instrument rating, lose control of the aircraft and crash into the field