Loss of Control in Flight: Beechcraft A36TP Bonanza (Soloy Turbine Conversion), N100JB; fatal accident occurred January 07, 2019 near Colusa County Airport (O08), California

Lionel J. Robin

December 8, 1948 - January 7, 2019

Lionel J. Robin

December 8, 1948 - January 7, 2019

Jeffrey Thomas Webber

January 7, 1953 - January 7, 2019

Jeffrey Thomas Webber

January 7, 1953 - January 7, 2019

Jeffrey Thomas Webber

January 7, 1953 - January 7, 2019

Aviation Accident Final Report - National Transportation Safety Board 

The National Transportation Safety Board not travel to the scene of this accident.

Additional Participating Entities: 
Federal Aviation Administration / Flight Standards District Office; Sacramento, California

Textron Aviation; Wichita, Kansas

Rolls Royce; Indianapolis, Indiana

Investigation Docket - National Transportation Safety Board:

https://data.ntsb.gov/Docket

Chalk Hills Consulting Group LLC

https://registry.faa.gov/N100JB

Location: Colusa, California

Accident Number: WPR19LA058

Date & Time: January 7, 2019, 10:50 Local

Registration: N100JB

Aircraft: Beech A36

Aircraft Damage: Destroyed

Defining Event: Loss of control in flight

Injuries: 2 Fatal

Flight Conducted Under: Part 91: General aviation - Personal

Analysis

The pilot, who did not possess a current medical certificate, departed in instrument meteorological conditions on a cross-country flight with a passenger onboard. A witness at the departure airport reported that at the time of takeoff, the cloud ceiling was about 500 ft above ground level with visibility of about 1 mile. Radar information revealed that the airplane turned to a southwesterly heading after departure, consistent with a heading toward their intended destination. The data showed that about 10 seconds after takeoff, as the airplane ascended through about 725 ft mean sea level (msl), a right turn was initiated. During the initial portion of the turn, the airplane continued to ascend to about 825 ft msl, where it remained for about 7 seconds. The airplane then began a descent while remaining in the right turn until impact.

Maneuvering the airplane in restricted visibility placed the pilot in conditions conducive to the development of spatial disorientation. The accident circumstances, including the tightening descending turn, and the subsequent high-energy impact, are consistent with the known effects of spatial disorientation. Additionally, examination of the engine revealed no evidence of any preexisting anomalies that would have precluded normal operation. Part of the flight control system was highly fragmented and could not be examined; however, the portions that remained intact did not exhibit any preexisting anomalies. Therefore, it is likely that the pilot was experiencing the effects of spatial disorientation when the accident occurred.

The pilot’s autopsy revealed severe cardiac disease, and although incapacitation as a result of this was possible, the pilot's loss of control suggests spatial disorientation was a more likely initiating event. Thus, it is unlikely that any symptoms from the pilot's severe cardiac disease contributed to this accident. The pilot also had bipolar disorder, but the extent of symptoms and whether they contributed to the accident could not be determined from the available information. However, the pilot had an established history of using medications to control the disease; therefore, some of the negative effects may have likely improved. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The pilot's loss of airplane control due to spatial disorientation shortly after takeoff in instrument meteorological conditions.

Findings

Personnel issues Aircraft control - Pilot

Personnel issues Spatial disorientation - Pilot

Environmental issues Below VFR minima - Effect on operation

Factual Information

History of Flight

Initial climb Loss of control in flight (Defining event)

Initial climb Collision with terr/obj (non-CFIT)

On January 7, 2019, about 1050 Pacific standard time, a Beech A36, N100JB, was destroyed when it was involved in an accident near Colusa, California. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

A witness located at Colusa Airport (O08) reported that he saw the airplane taxi out and heard the pilot announce his departure from runway 13 on the airport's common traffic advisory frequency. The witness estimated that at that time, the cloud ceiling was about 500 ft above ground level with visibility of about 1 mile.

Information provided by the Federal Aviation Administration (FAA) revealed that the pilot was issued an instrument flight rules clearance to Palo Alto, California, before departure; however, he did not contact air traffic control after departure. Radar data showed that the airplane departed runway 13 at O08 and turned to a southwesterly heading. (Figure 1) About 10 seconds later, as the airplane ascended through about 725 ft mean sea level (msl) and had a groundspeed of about 130 knots, a right turn was initiated. During the initial portion of the turn, the airplane continued to ascend to about 825 ft msl, where it remained for about 7 seconds. The data showed that the airplane then began a descent, with an increase in groundspeed, while continuing the right turn for about 15 seconds until radar contact was lost. The last recorded radar target was within the vicinity of the accident site and showed an altitude of 75 ft msl and a groundspeed of about 160 knots. 

Pilot Information

Certificate: Private 

Age: 66,Male

Airplane Rating(s): Single-engine land; Multi-engine land

Seat Occupied: Unknown

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: None 

None Last FAA Medical Exam:

Occupational Pilot: No

Last Flight Review or Equivalent:

Flight Time: 1500 hours (Total, all aircraft)

The pilot did not possess a valid medical certificate at the time of the accident. His most recent medical certificate application was dated January 18, 2005, at which time he reported 1,500 hours of total flight experience. Review of FAA records showed that the pilot had reported hay fever and knee pain along with intermittent use of chlorpheniramine (a sedating antihistamine available over the counter and often marketed with the name Chlor-TriMeton). Correspondence sent to the FAA in May 2006 stated that the airman had a diagnosis of bipolar affective disorder type II, a history of attempted suicide, and had been prescribed Effexor (generic: venlafaxine), Wellbutrin (generic: bupropion), and Lamictal (generic: lamotrigine). The pilot surrendered his medical certificate a few months later after the FAA requested further medical information, which he declined to provide.

The pilot's logbooks were not located during the investigation.

Aircraft and Owner/Operator Information

Aircraft Make: Beech

Registration: N100JB

Model/Series: A36 

Aircraft Category: Airplane

Year of Manufacture: 1984 

Amateur Built: No

Airworthiness Certificate: Normal

Serial Number: E-2203

Landing Gear Type: Retractable - Tricycle 

Seats: 6

Date/Type of Last Inspection: July 18, 2018 Unknown

Certified Max Gross Wt.: 3651 lbs

Time Since Last Inspection: 

Engines: 1 Turbo prop

Airframe Total Time: 3202.7 Hrs as of last inspection

Engine Manufacturer: Allison

ELT: Installed, not activated 

Engine Model/Series: 250-B17C

Registered Owner: 

Rated Power: 450 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: KMYV,62 ft msl

Distance from Accident Site: 21 Nautical Miles

Observation Time: 19:53 Local

Direction from Accident Site: 98°

Lowest Cloud Condition:

Visibility: 10 miles

Lowest Ceiling: Overcast / 7500 ft AGL

Visibility (RVR):

Wind Speed/Gusts: 9 knots / 

Turbulence Type Forecast/Actual:  /

Wind Direction: 160°

Turbulence Severity Forecast/Actual:  /

Altimeter Setting: 30.18 inches Hg 

Temperature/Dew Point: 12°C / 9°C

Precipitation and Obscuration: No Obscuration; No Precipitation

Departure Point: Colusa, CA (O08)

Type of Flight Plan Filed: IFR

Destination: Palo Alto, CA

Type of Clearance: IFR

Departure Time: 10:50 Local

Type of Airspace: Class E

The terminal aerodrome forecast (TAF) issued closest to O08 was about 26 miles east of the accident site. Between 0800 and 0900, the TAF forecast wind from 180º at 9 knots, visibility better than 6 miles, ceiling broken at 3,000 ft agl, overcast ceiling at 6,000 ft, altimeter setting 30.03 inches of mercury, with a temporary period from 0900 to 1100 of ceiling broken at 1,500 ft.

A search of the FAA automated flight service station provider, Leidos, indicated that no requests from the pilot for a weather briefing or to file a flight plan were made. It is unknown what the pilot reviewed to familiarize himself with the reported and forecasted weather conditions.

Airport Information

Airport: COLUSA COUNTY O08 

Runway Surface Type:

Airport Elevation: 49 ft msl 

Runway Surface Condition: Unknown

Runway Used: 

IFR Approach: None

Runway Length/Width:

VFR Approach/Landing: None

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: 39.153057,-122.019996 (est)

Examination of the accident site by local law enforcement revealed that the airplane impacted a water irrigation pond 1.8 miles southwest of O08. The airplane wreckage, which was mostly submerged within about 5 ft of water, was recovered to a secure location for further examination.

Examination of the recovered wreckage revealed that the airframe was fragmented into multiple pieces. The instrument panel was displaced, and multiple instruments had separated. One attitude indicator was located within the recovered wreckage and was disassembled. The gyro and gimbal exhibited extremely light scoring. One vacuum pump remained attached to an external drive assembly mounted on the firewall. The vacuum pump was disassembled, and all internal rotors and vanes were intact. The vacuum pump drive was intact and undamaged. Another vacuum pump was located within the recovered wreckage, and all internal components were separated and not located.

The left wing was bent and buckled throughout. The flap and aileron remained attached. The tip tank remained attached. The right wing was fragmented into multiple sections. The outboard tip tank, and inboard portion (gear well) of the wing were recovered. A majority of the right wing was not recovered.

Flight control continuity was unable to be established throughout the airframe. Fragments of the elevator, trim, and aileron control cables were located within the recovered wreckage. The fracture surfaces on the bellcranks and control cables exhibited evidence of being cut by recovery personnel or signatures consistent with overload separation.

The turbine engine was separated from its mount, and the compressor section was separated. The propeller gearbox and governor were separated and not recovered. The engine displayed extensive impact, crush, and fracture damage and was covered with dried mud and water residue. Multiple stages of compressor rotor blade bending and fractures opposite of rotation were observed. The gas producer

turbine 1st and 2nd stage nozzles exhibited marks consistent with turbine blade tip rub.

Examination of the recovered airframe and engine revealed no preimpact anomalies that would have precluded normal operation.

Additional Information

The FAA Civil Aeromedical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a “loss of proper bearings; 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 IFR conditions, frequent transfer between visual flight rules and IFR conditions, and unperceived changes in aircraft attitude.

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

The vestibular sense (motion sensing by the inner ear) in particular can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, 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.

Medical and Pathological Information

 According to the autopsy performed by Bennet Omalu Pathology, Stockton, California, the pilot’s cause of death was high velocity deceleration injury. Extensive coronary artery disease was identified in the right, left main, left anterior descending, and circumflex arteries, which were 90-99% occluded. Microscopy demonstrated evidence of previous ischemia including myofibrillary contraction band degeneration and cytoplasmic hypereosinophilia, which was multifocal but with no visible scar on the gross evaluation. In addition, the pilot had hypertensive cardiomyopathy and the pathologist reported a clinical history of poorly controlled diabetes with damage to his kidneys as well as bipolar disease.

Toxicology testing performed by NMS Labs on cavity blood at the request of the pathologist identified venlafaxine and its metabolite desmethylvenlafaxine, bupropion and its metabolite hydroxybupropion, and lamotrigine.

Toxicology testing performed by the FAA's Forensic Science Laboratory identified zolpidem, venlafaxine and its metabolite desmethylvenlafaxine, bupropion and its metabolite hydroxybupropion, and lamotrigine in liver and muscle tissue. The zolpidem level in the pilot was too low for the lab to quantify.

Zolpidem is a Schedule IV controlled substance available by prescription for the short-term treatment of insomnia; it is often marketed with the name Ambien. It is quickly sedating; users are instructed to take it only immediately before going to bed. Particularly during the initial period after taking the drug, a variety of psychoactive effects have been described, including "sleep driving" and other potentially dangerous events.

Venlafaxine is an antidepressant that can cause a variety of psychoactive effects but has not been shown to affect safety while operating a vehicle. Bupropion is an antidepressant or an adjunct to quit smoking. Bupropion can cause a number of psychoactive effects and increases the risk of seizure. Lamotrigine is an anti-seizure medication also indicated for mood stabilization in patients with bipolar disease. Lamotrigine may cause a variety of psychoactive effects; its direct effects on operating a vehicle have not been studied.