NTSB Factual Report

History of the Flight

On May 28, 1993, at 1330 hours Pacific daylight time, a Beech D-50E, N2R, crashed about 16 miles southwest of Lee Vining, California. The airplane was being operated as a visual flight rules (VFR) cross country personal flight to Carson City, Nevada, when the accident occurred. The airplane owned and operated by the pilot, was destroyed The certificated commercial pilot and three passengers received fatal injuries. Instrument meteorological conditions prevailed in the area at the time of the accident. The accident flight originated from Sequoia Field, Visalia, California, at 1230 hours as the return portion of a flight from Carson City to Visalia

The airplane failed to arrive at Carson City and relatives reported the airplane overdue to the Federal Aviation Administration, Reno, Nevada, Automated Fight Service Station (AFSS). On May 28, 1993, at 2330 hours, search personnel notified the Mather District Ranger Station, Yosemite National Park, that an emergency locator transmitter (ELT) signal had been heard in the vicinity of the Mt. Lyell area of the park. On May 29, 1993, about 0700 hours, search personnel located the airplane wreckage.

A park ranger reported that the weather conditions observed between1300 and 1400 hours on May 28, 1993, in the Tuolumne Meadows area (about 10 miles north of the accident site), consisted of; Overcast skies at about 12,000 feet, lowering to 10,000 feet at 1500 hours. Areas of layered clouds were visible; however, the mountain peaks were obscured by clouds. The temperature was about 48 degrees Fahrenheit with gusty winds from the west between 10 to 15 knots.

The park ranger also reported that he had talked with a hiker who had been in the Sunrise Mountain area (about 9 miles west of the accident site) before the time of the accident. The hiker indicated that while looking to the south, a white aircraft with blue trim was observed flying low over the terrain and under a solid overcast.

The accident occurred during the hours of daylight at latitude 37 degrees, 44.05 minutes north and longitude 119 degrees, 16.41 minutes west, at 11,800 feet mean sea level (MSL).

Crew Information

The pilot held a commercial pilot certificate with airplane single engine land and sea, and mulitengine land and sea ratings. The most recent second class medical certificate was issued to the pilot on April 7, 1992, and contained the limitation that the pilot must possess correcting lenses for near vision while exercising the privileges of his airman certificate.

No personal flight records were located for the pilot. The aeronautical experience listed on page 6 of this report was obtained from a review of the Airman and Medical Records Center located in Oklahoma City. The pilot reported on his last application for medical certificate on April 7, 1992, that his total aeronautical experience consisted of 1,000 hours, of which 16 hours were accrued in the preceding 6 months of the application date.

Aircraft Information

The airplane's recording hour meter was destroyed. The accumulated total hours on the airframe and engines is based on the last recorded annual inspection on April 5, 1993. At that time, the airplane had accumulated a total time in service of 3,654.1 flight hours

The left engine had accrued a total time in service of 981.1 hours of operation since being manufactured on June 3, 1981. The right engine had accrued a total time in service of 3,031.1 hours of operation, and 431.1 hours since being overhauled on December 12, 1986.

Meteorological Information

The pilot received a weather briefing from the Reno AFSS at 0715 hours, prior to departing Carson City. The pilot requested a standard weather briefing for a 0945 hour departure from Carson City, Nevada, to the Hangtown VOR, Placerville, California, then direct to Visalia, California. (A VOR is a ground based electronic navigation aid transmitting very high frequency navigation signals 360 degrees in azimuth, oriented from magnetic north). The pilot did not file a flight plan; however, he indicated that the time enroute for the flight would be between 1 hour 25 minutes, and 1 hour 30 minutes. There are no known communications indicating that the pilot obtained any subsequent weather briefings for the return portion of his return flight.

During the 0715 hours briefing, the flight service station specialist provided the pilot with meteorological information indicating in part: "The only flight precaution in the area is over the northern Sacramento Valley to Tahoe. Occasional mountain obscuration; VFR flight over those portions is not recommended when there is any mountain obscuration.

Current conditions along the route of flight reported at Carson City: 12,000 scattered; estimated 25,000 broken; visibility 40 miles; reporting few cumulus clouds, southwest through west. Over the Sierras, reporting: Scattered to broken mid-level clouds; unrestricted visibility; bases at or above 12,000 feet AGL. On the west side of the mountains, Fresno, Visalia area, mostly clear with a few scattered mid-level clouds. Visalia is an automated weather observation, reporting: clear sky below 12,000; visibility 10 miles; temperature 56; wind, 230 degrees at 4 knots.

The enroute forecast over the western Nevada portions: Scattered to cirrus clouds going over the Sierra Nevada Mountains. Calling for 9,000 to 11,000 feet broken clouds; possibility of widely scattered light rain showers or thunderstorms. Light rain showers is for the Tahoe area northward. The destination on the west side of the Sierras is calling for: Broken to cirrus form clouds all day. Winds for the route: Carson City area at 6,000 feet, 230 degrees at 8 knots; 9,000 feet, 190 degrees at 14 knots; 12,000 feet, 190 at 20 knots. Sacramento valley: 6,000 feet, 210 degrees at 8 knots; 9,000 feet, 210 degrees at 14 knots; 12,000 feet, 220 at 20 knots. San Joaquin Valley: 6,000 feet, 240 degrees at 6 knots; 9,000 feet, 230 degrees at 12 knots; 12,000 feet, 220 degrees at 18 knots.

The closest official weather observation station is Mammoth Lakes, California, which is located 22 nautical miles east of the accident site. At 1150 hours, a surface observation was reporting in part: Sky condition and ceiling, 6,000 feet scattered clouds, estimated ceiling, 15,000 feet, broken clouds; visibility, 50 miles; temperature, 58 degrees Fahrenheit; dew point, 19 degrees Fahrenheit; wind, 220 degrees at 11 knots; altimeter, 30.00 inHg.

A remote automated weather station at Tuolumne Meadows on May 28, 1993, at 1300 hours was reporting:

Overcast sky; high temperature, 49 degrees Fahrenheit; low temperature 27 degrees Fahrenheit; wind, from the west at 4 knots; remarks, no precipitation.

A review of the weather conditions present in the accident area was conducted by a National Transportation Safety Board meteorologist. Wind and temperature data from the National Weather Service, upper air station, located in Oakland, California, indicated that the freezing level was about 9,900 feet. Visual and infrared satellite imagesof the accident area indicated that the cloud tops were about 13,750 feet. A broad band of clouds was present over the Sierra Nevada Mountains. The NTSB weather factual report is included as Item 8 of this report.

Communications

After departure from Visalia, there were no known reports of communications with the accident airplane.

A cassette tape of the weather briefing that the pilot received from the Reno AFSS is included as Item 7 of this report.

A search for any radar track data of the accident airplane was conducted by the FAA. No radar data was found.

Wreckage and Impact Information

Safety Board investigators examined the airplane wreckage at the accident site on May 30, 1993. Impact impressions and the wreckage examination revealed that the airplane struck deep snow covered terrain on about a 305 degree heading (all heading/bearings noted in this report are oriented toward magnetic north). The impact site was located at the north end of a wide curving valley that terminated in a bowl shaped box canyon, with a sheer vertical ridge north of the impact site, oriented east and west.

The impact impression in the snow produced a slight left curving furrow into about 15 degree upsloping terrain, with the terrain sloping upward to about 33 degrees to the right of the impact. The impact scar was about 60 feet long, 12 feet wide and 3 to 4 feet deep. All of the airplane's major components were found at the main wreckage area. At the first point of snow contact was a broken landing light lens from the left wing. About 40 feet north of the lens, the left engine propeller was found separated from the engine and was buried in about 6 feet of snow. About 20 feet north of the left propeller, the right engine was found separated from the wing and was buried vertically in about 8 feet of snow with the propellers still attached.

The left engine separated from the wing and came to rest inverted about 6 feet north of the right engine. Adjacent to the left engine was the forward nose section and cockpit area to just aft of the front seats, also lying inverted. The entire lower portion of the fuselage at the wing attach points was separated and extensively damaged. The aft portion of fuselage from just forward of the cabin door to the tail had separated from the center wing carry-through area and was oriented 180 degrees from the impact; it was lying on the right side and the air-stair door was closed and latched.

The empennage came to rest in an upright position; it was torn and twisted 90 degrees counterclockwise from the fuselage. The left horizontal stabilizer was crushed aft and curled upward about mid-span. The right horizontal stabilizer was bent upward about mid-span. The right elevator trim tab actuator was found extended 1 inch and the left elevator trim tab actuator was found extended 3/4 inch. According to the manufacturer, the extended trim tab actuator corresponds to about a 4 degree tab down (nose up) and 14 degree tab down setting, respectively. The right and left flap actuators were retracted.

The right wing, with the engine mount still attached, separated from the fuselage at the attach point and came to rest inverted and parallel to the impact heading. The wing exhibited spanwise, aft chordwise crushing and folding. The aileron and flap remained attached to the wing. The right tip was crushed in an inboard direction and curled toward the underside of the wing.

The left wing was extensively crushed and shredded from the root end to outboard of the engine mount. The outboard end separated at the engine mount and displayed an upward 45 degree bend at the tip with aft crushing signatures. The left aileron separated from the wing and came to rest adjacent to the right wing. The left flap was extensively fragmented and crushed.

Due to the impact and damage, Safety Board investigators were unable to operate the flight controls by their respective control mechanisms; however, flight control continuity was established to the cables in the cabin/cockpit area. All of the flight control cable separated ends displayed a distorted and broom-straw like appearance. After recovery, the engines and propellers were examined on September 16, 1993, at Faith Aviation, Sacramento, California.

The left engine propeller assembly separated from the engine crankshaft leaving portions of the propeller spinner still attached to the spinner bulkhead. The blades were bent aft about 45 degrees about 6 inches outboard from the hub; the blades exhibited torsional twisting. The propeller mounting bolts were sheared at the crankshaft flange and exhibited 45 degree angle fracture surfaces. The aft section of the spinner bulkhead exhibited 1/4 inch deep impressions that extended for about 2 inches around the circumference of the plate.

The right engine propeller assembly remained attached to the crankshaft. The blades were bent aft in a similar manner as the left engine and exhibited torsional twisting. One blade exhibited "S" bending. The propeller spinner was deformed and crushed aft over the hub. The spinner, viewed from the front of the engine, exhibited a spiral, counterclockwise rotational scoring on the interior portion of the spinner. The low pitch blade stops of each blade were broken. The propeller piston was extended to a low pitch (high RPM) position.

Both engines sustained impact damage to the underside and front portion of their engine cases. Both crankshafts could be rotated by the propellers. Gear and valve train continuity was established for both engines and thumb compression in each cylinder was noted during the crankshaft rotation. The engine oil sump screens of both engines were free of contaminates.

Both magnetos from both engines produced spark at all terminals upon hand rotation. The dual massive electrode spark plugs did not exhibit any unusual combustion signatures.

The pressure carburetor from the left engine separated at impact and was not located. The right engine carburetor was broken from the engine and the oil sump was broken. A small amount of fuel was located in the carburetor inlet line to the fuel screen. The fuel screen was free of contaminates. A small amount of fuel was located in the outlet port of the right engine fuel pump. The right engine wet style vacuum pump vanes were undamaged and had the presence of lubrication.

Medical and Pathological Information

A post mortem examination of the pilot was conducted by the Madera County Coroner's Office on May 31, 1993. The examination revealed that the cause of death for the pilot was attributed to multiple severe blunt force injuries. No pre-existing conditions were noted during the autopsy which would have adversely affected the pilot's abilities to pilot an aircraft.

A toxicological examination of the pilot was conducted by the Department of Defense, Armed Forces Institute of Pathology, on June 15, 1993, and revealed a carboxyhemoglobin saturation in the blood of 2 percent. The report noted that carboxyhemoglobin saturations of 0 to 3 percent are expected for non-smokers. The examination was negative for all screened drugs and alcohol.

Additional Information

Wreckage Release

The Safety Board released the wreckage, located at Faith Aviation, to the owner's representatives on September 17, 1993. No parts or components were retained by the NTSB.

NTSB Probable Cause

The pilot's inadequate weather evaluation; inadequate in-flight planning and decision making; and the pilot's continued VFR flight into instrument meteorological conditions.