NTSB Factual Report

HISTORY OF FLIGHT

On June 29, 2008, about 0756 central daylight time, a Beech 95-B55, N727BC, was destroyed following a loss of control in flight after takeoff from Walker County Airport (JFX), Jasper, Alabama. The certificated private pilot/owner and three passengers were fatally injured. Instrument meteorological conditions (IMC) prevailed for the flight that originated at JFX about 0750. No flight plan was filed for the personal flight that was destined for Jack Edwards Airport (JKA), Gulf Shores, Alabama, and conducted under the provisions of 14 Code of Federal Regulations Part 91.

Several witnesses provided written statements and were interviewed at the scene. According to one witness, he was in his backyard disconnecting his boat trailer from his vehicle, when the sound of the airplane caught his attention. He looked up and estimated that the airplane was 300 to 400 feet above the trees and below the cloud layer. The witness added, "I saw the airplane plain as day. The engine on that plane sounded like one engine was revving."

With a model of an airplane in his hand, the witness demonstrated the airplane in a nose-up pitch attitude of about 30 degrees, and descending in a wings-level, tail low spin around the yaw axis. The engine sound was continuous, with increasing and decreasing volume as the airplane rotated towards and away from his position. The witness stated that his property bordered lands owned by the State of Alabama, where the airplane came to rest. He estimated that the distance from where he stood to the crash site was about 150 yards. According to the witness, "The airplane didn't look like it was falling that fast, just in a slow spiral. I probably watched it go around four of five times before I lost sight of it."

A second witness stated that his attention was drawn to the sound of the airplane, and then he walked out on his back porch, and saw the airplane about 600 feet above the ground. He said that he heard one engine "sputtering," before the engine "quit." He said the other engine was "screaming." With a model of an airplane in his hand, the witness demonstrated the airplane in a nose-up pitch attitude about 30 degrees. He added that the airplane appeared to have "too much weight for the incline after take off."

A third witness stood with her husband about 300 yards from the crash site when she heard an airplane, and then heard the engine "switched off." When she looked up, the airplane appeared to be in a nose-up climb, as it appeared, "I thought to level off." Instead, "the engines went completely off, then the nose went down and the airplane descended and he started spiraling. The airplane went around 3 times in the spiral during the descent and I heard a sound like he was trying to crank the engine, but only one engine, and then it went down behind the trees."

Her husband stated that the airplane climbed and descended in a spiral three times before it descended behind the trees. He said the engine sound was "screaming" and "getting all it could get" during the climb, but that there was no engine sound during the descent.

Radar data from the Federal Aviation Administration (FAA) revealed that a target identified as the accident airplane, first appeared on a southerly track, about 1 mile southwest of JFX, at 1,200 feet. The airplane continued on a southerly track for about 2 miles, accelerated from 100 knots to 120 knots, and climbed to 1,700 feet. The airplane then turned to the north, and during the turn, descended to 1,300 feet and accelerated to 140 knots. Over the next 2 miles, on an s-shaped northerly track, the airplane climbed and descended between 1,300 feet and 2,600 feet, at speeds that varied between 100 knots, and 160 knots. The final radar targets depicted a descent, and were clustered approximately over the crash site, 1 mile west of JFX.

PERSONNEL INFORMATION

The pilot held a private pilot certificate, with ratings for airplane single engine land and multiengine land. The pilot did not hold an instrument rating. His most recent FAA third-class medical certificate was issued on April 24, 2008. Examination of the pilot's logbook revealed that he had logged 539 total hours of flight experience, 221.9 hours of which were in the Beech 55. The pilot's most recent flight review was completed on May 17, 2006.

The pilot's three most recent flights were in November 2007, March 2008, and a flight of .5 hours the day prior to the accident. According to the pilot's flight instructor, and the owner of the local fixed base operator that serviced the airplane, the 1/2-hour flight on the day prior to the accident was to satisfy currency requirements prior to the accident flight to Gulf Shores, Alabama.

AIRCRAFT INFORMATION

According to the FAA and maintenance records, the airplane was manufactured in 1982, and had accrued 1,756 total aircraft hours. The most recent annual inspection was completed April 16, 2008, at 1,717.2 aircraft hours.

The manufacturer's maximum allowable gross weight for the airplane was 5,100 pounds. The most recent weight and balance information in the maintenance logbooks was dated August 2001. The contents of the airplane were removed and weighed, and using them, the weights of the occupants, and an estimated fuel load of 690 pounds, the calculated weight of the airplane at the time of the accident was 5,303 pounds. The center-of-gravity range at maximum gross weight was between station 81 and 86. The calculated center-of-gravity at takeoff was 83.9.

Prior to takeoff, an 80-pound dog was placed unrestrained in the aft baggage area (Station 180), and left free to move fore and aft of that station.

METEOROLOGICAL INFORMATION

At 0756, the weather reported at Halleyville/Posey Field (1M4), Halleyville, Alabama, 26 miles north of the accident site, included an overcast ceiling at 300 feet, and winds from 240 degrees at 6 knots. The visibility was 5 miles. The temperature was 22 degrees Celsius (C) and the dew point was 21 degrees C.

At 0753, the weather reported at Birmingham International Airport (BHM), Birmingham, Alabama, 34 miles southeast of the accident site, included an overcast ceiling at 1,200 feet, and winds from 220 degrees at 8 knots. The visibility was 9 miles. The temperature was 24 degrees C, and the dewpoint was 20 degrees C.

In a written statement, a local flight instructor, who was practicing instrument approaches at JFX at the time of the accident flight, said his airplane entered the overcast ceiling at 700 feet and reached the top of the cloud layer about 4,000 feet. The field elevation at JFX was 482 feet.

Information from the FAA revealed that there was no record that the pilot requested a weather briefing, or filed a flight plan prior to departure.

WRECKAGE AND IMPACT INFORMATION

The airplane was examined at the site on June 30, 2008. There was an odor of fuel present, and all major components were accounted for at the scene. The airplane came to rest upright in flat, wooded terrain. The trees surrounding the wreckage were undisturbed, but the trees and branches directly beneath and above the wreckage displayed breaks and angular cuts. Several small saplings in the vicinity of both the left and right propellers exhibited clean angular cuts.

The cockpit, cabin area, and empennage were crushed upwards in compression. The cabin roof was removed by rescue personnel prior to examination. The cockpit, engine control quadrant, and instrument panel were completely destroyed by impact. The center column to the dual yoke was bent downward 90 degrees, and the left control arm was separated at the center mixing unit. The rudder pedals were crushed into the cockpit, and the pilot's side rudder control tube was fractured by impact.

Control cable continuity was established from the ailerons to the root of each wing, and also from the rudder and elevators to the cabin. Flap controls were fractured at various points along the system by impact, but examination of the flap actuator revealed a position consistent with retracted flaps.

The left and right wings, and their respective engine nacelles, were also crushed upwards in compression. All fuel bladders were punctured by impact, but all contained fuel. Both nacelles were bent downward about 30 degrees at their respective engine firewalls. Both engines were still in their nacelles with their propellers attached. Both three-bladed propellers showed two blades above the ground, and one blade buried beneath each nacelle. The tree trunk immediately adjacent to the left propeller displayed deep arcing slash marks that penetrated the tree in an upward direction.

The wreckage was removed from the site, and the examination was continued on July 1, 2008, at the Walker County Airport. Flight control continuity was then confirmed from the ailerons, rudder, and elevators, all the way to the pilot controls.

The fuel system continuity was established by accessing both main fuel valves, because the cockpit fuel selectors were displaced from their housings. Shop air was applied to the right main fuel supply inlet and exited through the engine supply outlet. Shop air was then introduced to the main fuel supply line at the left engine firewall, and exited into the left inboard fuel bladder.

Examination of the left engine revealed the left magneto was separated at its mount, and the right magneto was still attached. The engine-driven fuel pump was removed and rotated freely with no binding. Fuel was present at the fuel manifold inlet line.

The left propeller was removed, and the left engine crankshaft was rotated by hand. Continuity was established through the powertrain and valvetrain to the accessory section. Compression was confirmed using the thumb method. Spark was produced by the right magneto at the top leads. The bottom leads were not accessible. The left magneto was impact damaged, and did not rotate.

The right engine-driven fuel pump was removed, rotated by hand, and ejected fuel from the outlet side. The right propeller was removed, and the right engine crankshaft was rotated by hand. Continuity was established through the powertrain and valvetrain to the accessory section. Compression was confirmed using the thumb method. Both magnetos were separated at their mounts. The magnetos were rotated by hand and produced spark at all top terminal leads. The bottom spark plugs were inaccessible.

A detailed examination of the engines was conducted in Mobile, Alabama, under the supervision of a National Transportation Safety Board investigator. The examination revealed no pre-impact anomalies.

MEDICAL AND PATHOLOGICAL INFORMATION

The State Medical Examiner of the Alabama Department of Forensic Sciences, Montgomery, Alabama, conducted a postmortem examination of the pilot on July 19, 2008. The reported cause of death was "extensive blunt force injuries."

The FAA Bioaerautical Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing for the pilot.

ADDITIONAL INFORMATION

Aircraft Weight and Balance Handbook

According to the FAA's Aircraft Weight and Balance Handbook (FAA-H-8083-1A), there are many factors that lead to efficient and safe operation of aircraft. Among these factors is proper weight and balance control.

The weight and balance system commonly employed among aircraft consists of three equally important elements: the weighing of the aircraft, the maintaining of the weight and balance records, and the proper loading of the aircraft. An inaccuracy in any one of these elements nullifies the purpose of the whole system. The final loading calculations will be meaningless if either the aircraft has been improperly weighed, or the records contain an error.

Improper loading cuts down the efficiency of an aircraft from the standpoint of altitude, maneuverability, rate of climb, and speed. It may even be the cause of failure to complete the flight, or for that matter, failure to start the flight. Because of abnormal stresses placed upon the structure of an improperly loaded aircraft, or because of changed flying characteristics of the aircraft, loss of life and destruction of valuable equipment may result. The responsibility for proper weight and balance control begins with the engineers and designers, and extends to the aircraft mechanics that maintain the aircraft and the pilots who operate them.

The ideal location of the center of gravity (CG) was very carefully determined by the designers, and the maximum deviation allowed from this specific location was calculated.

The pilot in command of the aircraft has the responsibility on every flight to know the maximum allowable weight of the aircraft and its CG limits. This allows the pilot to determine on the preflight inspection that the aircraft is loaded in such a way that the CG is within the allowable limits.

Balance control (location of the CG of an aircraft) is of primary importance to aircraft stability, which determines safety in flight. The CG is the point at which the total weight of the aircraft is assumed to be concentrated, and the CG must be located within specific limits for safe flight. Both lateral and longitudinal balance are important, but the prime concern is longitudinal balance; that is, the location of the CG along the longitudinal or lengthwise axis.

As long as the CG is maintained within the allowable limits for its weight, the airplane will have adequate longitudinal stability and control. If the CG is too far aft, it will be too near the center of lift and the airplane will be unstable, and difficult to recover from a stall. If the unstable airplane should ever enter a spin, the spin could become flat and recovery would be difficult or impossible.

Airplane Flying Handbook

According to the FAA's Airplane flying Handbook (FAA-H-8083-3A), the flight characteristics of the multiengine airplane will vary significantly with shifts of CG. At forward CGs, the airplane will be more stable, with a slightly higher stalling speed, a slightly slower cruising speed, and favorable stall characteristics. At aft CGs, the airplane will be less stable, with a slightly lower stalling speed, a slightly faster cruising speed, and less desirable stall characteristics. Forward CG limits are usually determined in certification by elevator/stabilator authority in the landing roundout. Aft CG limits are determined by the minimum acceptable longitudinal stability. For this reason, it is contrary to the airplane's operating limitations and the CFRs to exceed any weight and balance parameter.

FAA Advisory Circular 61-134

"According to National Transportation Safety Board (NTSB) and FAA data, one of the leading causes of GA accidents is continued VFR flight into IMC... The importance of complete weather information, understanding the significance of the weather information, and being able to correlate the pilot's skills and training, aircraft capabilities, and operating environment with an accurate forecast cannot be emphasized enough... VFR pilots in reduced visual conditions may develop spatial disorientation and lose control, possibly going into a graveyard spiral..."

An FAA designated pilot examiner (DPE) who was a close friend of the pilot's said that over the course of many years, he and others at the airport had spoken to the pilot about staying current, about obtaining instrument flight training, and the need for the accident pilot to earn his instrument rating. One airport patron mentioned that the accident pilot was "an auto-pilot pilot. He would take off into the clouds, select auto-pilot, and go." When asked if he agreed with that statement about the accident pilot, the DPE replied, "Yes."

When asked how many times the accident pilot had been counseled by his friends, family, fellow pilots, and the DPE himself about flying VFR in IMC conditions without benefit of an instrument rating, or filing an instrument flight plan, the DPE replied, "Several."

NTSB Probable Cause

The pilot's intentional visual flight into known instrument meteorological conditions, resulting in spatial disorientation and a subsequent loss of control in flight. Contributing to the accident was the overweight and aft-center-of-gravity condition of the airplane at takeoff.