NTSB Factual Report

HISTORY OF FLIGHT

On October 29, 2015, at 0754 central daylight time, a Raytheon Aircraft Company A36 airplane, N3BE, impacted terrain shortly after departing from the Russellville Regional Airport (RUE), Russellville, Arkansas. The commercial-rated pilot and three passengers were fatally injured, and the airplane was destroyed. The airplane was registered to and operated by Valley Motors, Inc., under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Day instrument meteorological conditions prevailed for the flight, which departed on an instrument flight rules (IFR) flight plan with a planned destination of McGhee Tyson Airport (TYS), Knoxville, Tennessee. The flight was originating at the time of the accident.

A mechanic at RUE noticed the airplane taxi out and depart normally from runway 7 with the engine sounding "excellent." A fixed base operator employee observed the airplane's takeoff to be normal with no engine anomalies. Two witnesses east of the airport heard the airplane on departure. One perceived the engine to be "cutting out," and the other noticed the engine "sputtering."

An airport surveillance video camera recorded the airplane depart from runway 7 at RUE, which has a field elevation of 404 ft mean sea level (msl). The airplane subsequently impacted a ridge about 1 mile from the runway's departure end at an elevation of 620 ft msl. A postimpact fire consumed most of the airplane.

PERSONNEL INFORMATION

The pilot, age 65, held commercial pilot and flight instructor certificates with airplane single-engine land, multi-engine land, and instrument ratings. On his most recent Federal Aviation Administration (FAA) airman medical application, dated February 23, 2015, the pilot reported 12,716 total flight hours. Pilot logbooks were not available for examination during the investigation. According to other pilots who had worked with him during his career, the accident pilot had worked as a flight instructor and flown for multiple Part 135 operators for over 25 years. The pilot had extensive experience flying out of RUE.

On his most recent FAA medical application, the pilot listed previously reported medical conditions that included thyroid cancer and thyroid removal (1979), gastroesophageal reflux disease, atrial fibrillation causing fainting (2004), and chronic kidney disease. He also reported using the following medications: terazosin, amiodarone, calcitriol, pravastatin, ranitidine, levothyroxine, and lisinopril. Terazosin, brand name Hytrin, is used to treat symptoms from an enlarged prostate gland and to help control blood pressure. Amiodarone, brand name Cordarone, is an anti-arrhythmic drug used to prevent recurrence of atrial fibrillation. Calcitriol is a prescription form of Vitamin D and is used to treat deficiencies or problems managing calcium balance due to kidney or parathyroid disease. Pravastatin, brand name Pravachol, is used to treat high cholesterol. Ranitidine is an over-the-counter medication, brand name Zantac, and is used to treat heartburn. Levothyroxine, brand name Synthroid, is a replacement thyroid hormone. Lisinopril, brand names Prinivil and Zestril, is a blood pressure medication.

At the time of his most recent FAA medical examination, the pilot provided information from his cardiologist regarding his heart condition and received a time-limited special issuance second class medical certificate. The medical certificate was limited by a requirement for corrective lenses and marked, "not valid for any class after February 29, 2016."

AIRCRAFT INFORMATION

The airplane, a Raytheon Aircraft Company A36, serial number E-3300, was issued a standard airworthiness certificate on February 7, 2000. The airplane was equipped with a Continental IO-550-B engine, serial number 684769, and a Hartzell 3-bladed aluminum-hub propeller. The airplane's Honeywell avionics suite included a Bendix/King KFC 225 Automatic Flight Control System and Garmin 430W/530W navigation systems. The airplane's last annual inspection was performed on June 1, 2015, at a total airframe time of 722.3 flight hours.

METEOROLOGICAL INFORMATION

At 0753, the weather observation station at RUE reported the following conditions: wind calm, visibility 4 miles, overcast clouds at 200 ft above ground level (agl) with mist, temperature 12° C, dew point 11° C, and altimeter setting 29.92 inches of mercury.

At 0819, the weather observation station at RUE reported the following conditions: wind 010 degrees at 4 knots, visibility 3/4 miles, overcast clouds at 200 ft agl with mist, temperature 12° C, dew point 11° C, and altimeter setting 29.93 inches of mercury.

The pilot used the Direct Users Access Terminal System (DUATS) to obtain electronic weather briefings and accessed the system three times between the evening before the accident and the morning of the accident. The last access, at 0518, included a low-level weather briefing for a flight between Russellville, Arkansas, and Knoxville, Tennessee. The briefing included observations of IFR conditions at RUE and observations from several other stations en route of marginal visual flight rules to IFR conditions in mist.

WRECKAGE AND IMPACT INFORMATION

The airplane collided with treetops in a rural area and then struck a stone retaining wall and the slope of a hill. The airplane came to rest 282 ft beyond the first tree strike on a heading of 310°. The engine separated from the airplane and was found lying in an inverted position uphill from the airframe.

The propeller was separated from the engine, the propeller spinner was crushed aft, and all three propeller blades remained attached to the propeller hub. Multiple tree limbs and branches that displayed diagonal sharp cuts and black paint transfers consistent with propeller strikes were found at the base of pine trees.

All six engine cylinders remained secured to the crankcase. The right-side cylinders sustained significant thermal damage, which partially melted the rocker covers and destroyed the ignition leads. The left-side cylinders sustained very little thermal damage. With the bottom sparkplugs removed, the cylinders were examined using a lighted borescope. No anomalies were noted with the cylinder barrels, pistons, cylinder heads, valves, or valve seats.

The magnetos remained secured to the engine, and the ignition harness remained attached to the magnetos. The bottom sparkplugs displayed very little wear and little-to-no combustion deposits when compared to the Champion Aviation Service Manual (AV6-R). The magneto's drives were intact, and impulse couplings could be heard and felt during manual rotation of the drive shafts. Sparks were observed on the distributor block towers during manual rotation of the left magneto. Sparks were not observed during manual rotation of the right magneto. The right magneto's housing cover was removed, and it was noted that the capacitor was thermally distorted and a portion of the capacitor's wire insulation was partially melted exposing some of its wires. When the right magneto's drive shaft was rotated with the capacitor removed, a spark was observed across the points as they opened.

The crankshaft was manually rotated, and continuity was confirmed from the propeller flange to the accessory end and out to each piston and each cylinder valve train. The left-side cylinders all produced thumb compression during crankshaft rotation. Due to thermal damage, thumb compression could not be obtained on the right-side cylinders.The engine-driven fuel pump sustained thermal damage, and it was disassembled with no anomalies noted. The throttle body and fuel metering unit were separated from the engine, and the throttle valve was near a full open position. The mixture cable remained attached to the mixture control lever, and the throttle lever was fractured near the cable attach area but remained attached to the throttle shaft. The fuel inlet screen was removed from the metering unit, and although some black debris was found on the screen, it was not obstructed.

The fuel manifold valve remained attached to the engine, and residual fuel was found in the manifold valve body. The fuel injector lines remained attached to the fuel injector nozzles, which remained secured to their cylinders. All the nozzles were clear of debris except for the No. 1 nozzle, which contained dirt and debris.

The left and right flap actuator extensions corresponded to a flap retracted position. The landing gear actuator was in a retracted position, and the landing gear emergency extension hand crank was in a stowed position. The airspeed indicator was thermally damaged with the pointer indicating 120 knots. No anomalies were noted with the flight control system, vacuum pump, or attitude gyro. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

MEDICAL AND PATHOLOGICAL INFORMATION

According to the autopsy report from the Arkansas State Crime Laboratory, Medical Examiner Division, the pilot's cause of death was multiple blunt injuries, and the manner of death was accident. A focal area of 70% narrowing by atherosclerotic plaque was identified in the left anterior descending coronary artery. Aside from this one area of severe coronary artery disease, the examination of the heart was unremarkable.

Toxicology testing performed by the FAA's Bioaeronautical Research Sciences Laboratory identified terazosin in blood, as well as pravastatin, ranitidine, terazosin, and salicylate in urine. Terazosin, pravastatin, and ranitidine are described above and had been reported to the FAA. Salicylate is a metabolite of aspirin, an over-the-counter, anti-inflammatory drug.

TESTS AND RESEARCH

At maximum gross weight, the airplane's climb rate was calculated to be 1,150 ft per minute, based on full engine power and 100 knots indicated airspeed. The minimum required IFR departure climb rate to safely clear terrain on takeoff from runway 7 at RUE was calculated to be 835 ft per minute at 100 knots ground speed and 955 ft per minute at 120 knots ground speed.

ADDITIONAL INFORMATION

On December 1, 2014, the pilot started a 5-day King Air 200 initial simulator training course conducted by SIMCOM Aviation Training. After the fourth day of this training, the pilot voluntarily withdrew from the course at the recommendation of his instructor. The instructor stated that the pilot's performance was below standards due to frequently "falling behind the aircraft" and task saturation issues, especially during instrument procedures.

From February 2015 until July 2015, the pilot flew a King Air 200 as second-in-command. The pilot-in-command of these flights stated that the pilot's multi-tasking abilities and situational awareness were a weak area, including an episode when he landed with the brakes engaged, which blew both main tires. He further stated that the pilot tended to have instrument fixation issues, struggled to use the flight director properly, and sometimes did not reference the attitude indicator enough during critical phases of flight.

Other pilots familiar with the pilot's earlier flying career stated that he was a very competent, conscientious, and skillful pilot. A pilot who flew at the same company that employed the accident pilot several years before the accident stated that the pilot flew at this company for 20 to 25 years without failing a check ride.

NTSB Probable Cause

The pilot's failure to maintain a sufficient climb rate during departure in instrument meteorological conditions, which resulted in controlled flight into terrain.