NTSB Factual Report

HISTORY OF FLIGHT

On April 6, 2002, approximately 1533 central standard time, a Beech D-45 single-engine airplane, N6VY, impacted heavily wooded terrain following a loss of control during a go-around at the Minden-Webster Airport (F24), near Minden, Louisiana. The airplane was owned and operated by the private pilot under 14 Code of Federal Regulations Part 91. Both the private pilot, who occupied the front seat, and the pilot rated passenger, who occupied the aft seat, were fatally injured. The airplane was substantially damaged. Visual meteorological conditions prevailed for the local flight for which a flight plan was not filed. The personal flight departed F24 approximately 30 minutes prior to the accident.

Witnesses, local authorities, and acquaintances reported that both pilots were in the process of moving to Minden. The private pilot (front seat) had recently accepted a position with a local hospital, and the pilot rated passenger (aft seat) had a part time position as the airport manager for the City of Minden. The airplane had been in a hangar at the airport for several days, during which time the pilots had become acquainted and discussed flying the airplane.

The airplane was observed departing from runway 01, and subsequently departed the traffic pattern. The was observed by some of the witnesses at the airport performing a series of maneuvers at approximately 2,000 to 3,000 feet above the airport.

The airplane was then observed entering the traffic pattern, and performed a series of touch and goes on runway 01. Some of the witnesses observed that the pilot was having problems with correcting for the prevailing right crosswind. During their fourth approach, the aft seat pilot radioed to the Unicom operator and requested that she "come out and watch his landing." During the fourth approach, the airplane was observed drifting to the west of centerline with the flaps fully extended. Witnesses reported that the airplane stalled, and full power was heard being applied. The nose of the airplane was reported to pitch-up, as the airplane rolled into a 90-degree bank to the left. Subsequently, the airplane assumed a nose low attitude and descended uncontrolled to the ground. Witnesses reported hearing the sound of engine noise until ground impact.

PERSONNEL INFORMATION

The private pilot held the airplane single-engine land rating issued on November 13, 1982. According to the logbook, reviewed by the NTSB investigator-in-charge (IIC), the private pilot's accumulated flight time from December 29, 1985, through February 23, 2001, was 1,012.3 hours in the accident airplane. On July 26, 2000, the FAA medical examiner issued the private pilot a third class medical certificate with the limitation: Holder shall wear correcting glasses while exercising the privileges of his airman certificate.

The pilot rated passenger held the FAA commercial pilot certificate with the airplane single-engine land and instrument ratings. He held private pilot privileges for the multiengine land airplane. On June 5, 2001, he was issued the flight instructor certificate with the airplane single engine rating. On April 2, 2001, the pilot was issued a first class medical certificate without limitations. The pilot rated passenger's accumulated flight time was 321.5 hours with zero time in the accident airplane.

AIRCRAFT INFORMATION

The 1955 Beech D45 ( military T-34B), serial number BG-221 (military 140887) airplane was equipped with the Continental O-470-4 reciprocating engine (serial number 116057) rated at 225 horsepower with a Beech model 278-102 two bladed propeller (serial number 1496) installed.

Maintenance records indicated a total airframe time of 11,142.3 hours verified from military records dated August 1964, and the annual inspection performed on July 10, 1980. The airplane (N3565G) was issued the FAA airworthiness certificate on July 11, 1980. Registration (N6VY) to the current owner was dated November 22, 1983.

On December 12, 1996, the engine was removed from N6VY for a major overhaul and reinstalled at 0.00 time. On September 1, 2001, the last annual inspection was performed at the accumulated airframe time of 12,251.3 hours and an engine time of 118.6 since major overhaul (SMOH).

According to the City of Minden aviation fueling records, the airplane was refueled with 29.4 gallons of aviation fuel on March 15, 2002.

METEOROLOGICAL INFORMATION

At 1456, the weather observation facility at Shreveport (SHV), Louisiana, approximately 29 nautical miles northeast of the accident site, reported the wind 130 degrees at 8 knots, ceiling 13,000 scattered, 16,000 broken, visibility 10 statute miles, and the altimeter setting 30.16 inches Mercury.

Witnesses and local authorities reported the wind at the accident site was from the east at 10 knots gusting to 20 knots.

AERODROME INFORMATION

The airport (F24), located approximately 2 miles northwest of Minden, is owned and operated by the City of Minden, Minden, Louisiana. F24, is a non-towered airport with runway 01/19. Runway 01/19 is an asphalt runway, 5,001 feet long and 75 feet wide. Runway 01 elevation is 278 feet, and the runway 01 has obstructions (45-foot trees, 8:1 slope to clear) 300 feet left of the runway centerline.

WRECKAGE AND IMPACT INFORMATION

The Global Positioning System (GPS) location of the accident site was 32 degrees 38.59 minutes North; 093 degrees 17.90 minutes West. The airplane was found in a nose low attitude (approximately 80 degrees) on a measured magnetic heading of heading of 130 degrees in the wooded area 967 feet west of the centerline of runway 01, 1,521 feet from the departure end of runway 01, and 930 feet from the left edge of runway 01. The ground crater measured approximately 5 feet wide and 2 1/2 feet deep. The landing gear was found in the extended position, and the flaps were retracted. Both cockpits and instrument panels were destroyed. The leading edge of the left wing, and the inboard leading edge of the right wing were crushed toward the wing spars. The integrity of the fuel system was compromised. Flight control continuity was confirmed for the elevators and rudder. The propeller was found separated from the engine. One propeller blade was straight, and one propeller blade had nicks along the outboard trailing edge. The airplane was recovered to a hangar at the airport (F24) for further examination.

The fuel gascolator was examined and no debris was found on the fuel screen. The stall warning system was tested at the wing and found operational. According to the aircraft representative, the aileron tab was found 2 degrees tab up (aileron down), the elevator tab 2 degrees tab down (elevator up), and the rudder 1 degree tab left (nose right). The front and rear engine throttle controls were found full forward, and the propeller control position mid-range. The aileron flight control assembly components (forward and aft torque tube support bracket, aileron bellcrank arm actuator, and the aft flight control stick tube were found fractured in the flight control system and were retained by the Board for further examination.

The engine crankshaft was rotated and continuity was confirmed to all the cylinders and to the accessory gears at the rear of the engine. Hand compression and valve action was noted on all the cylinders. The oil pump rotated. The generator rotated. The oil sump and screen were examined and no debris was found on the oil screen.

The Bendix model RS-5BD-1 throttle body/metering unit (part number 25243534, serial number 3897) had the fuel injector separated from the unit. The throttle valve was attached and in the idle position. The fuel valve and mixture control were free to move. The Bendix model LS6LN-28, part number 10-52350-20, serial number 9090511 (right), serial number 9051263 (left) magnetos exhibited impact damage, and the left magneto was found separated from the engine. The fuel pump (part number RG908H1, serial number B-8496) rotated, and no internal damage was found during disassembly of the unit. The Woodward propeller governor (part number 210060, serial number 506812) was found free to rotate. Disassembly of the unit did not reveal any internal damage. Both magnetos, the throttle body/metering unit, injector lines, and flow divider were retained by the Board for further examination.

MEDICAL AND PATHOLOGICAL INFORMATION

Both autopsies were performed by the Mississippi State Medical Examiner's Office, near Brandon, Mississippi. The medical examiner took specimens from both pilots, including blood, brain, gastric, heart, kidney, liver, lung, muscle, spleen, and vitreous.

The following pertinent information was extracted by NTSB Medical Officer from the report of autopsy performed on the private pilot: The autopsy report concludes "... the decedent was noted to have succumbed secondary massive craniocerebral trauma suffered in an airplane crash. Evidence of significant underlying disease is not appreciated. ..."

The following pertinent information was extracted by NTSB Medical Officer from the report of autopsy performed on the private pilot: The autopsy report concludes "... the decedent was noted to have succumbed secondary massive craniocerebral trauma suffered in an airplane crash. Evidence of significant underlying disease is not appreciated. ..."

The FAA Civil Aeromedical Institute's (CAMI) Forensic Toxicology and Accident Research center examined the specimens taken by the medical examiner. The CAMI toxicological findings for the commercial pilot showed no indication of alcohol or performance-impairing drugs at the time of the accident.

The CAMI toxicological findings for the private pilot were positive for the following drugs: 0.393 (ug/ml, ug/g) diazepam detected in blood; 2.081 (ug/ml, ug/g) diazepam detected in liver; 1.036 (ug/ml, ug/g) nordiazepam detected in blood; 5.542 (ug/ml, ug/g) nordiazepam detected in liver; 0.142 (ug/ml, ug/g) oxazepam detected in blood; 0.084 (ug/ml, ug/g) temazepam detected in blood. The CAMI non quantified findings for the private pilot was positive for propanolol detected in the blood and liver.

According to Dr. Baisden (FAA Acting Southwest Regional Flight Surgeon) the use of diazepam (Valium, an anti-anxiety agent) or temazepam (restoril, a sedative-hypnotic), are disqualifying medications if taken on a regular basis. If these medications are used only occasionally, there is a 72-hour waiting period before the pilot would be allowed to fly. Review of past applications show this pilot failed to report these medications to the FAA. Propanolol (inderal), which was prescribed for essential tremors of the head and neck, was reported on the airman’s last physical examination.

The following pertinent medial information was extracted by the NTSB medical Officer from the medial records maintained on the private pilot occupying the front seat by the FAA Civil Aeromedical Institute Aeromedical Certification Division:

2/23/95 - Application for Airman Medical Certificate indicates "no" under item 17. "Do you currently use any medications" and "no" under items 18.1. "neurologic disorders" and 18m. "mental disorders."

2/29/96 - Application for Airman Medical Certificate indicates "yes" under item 17. "Do you currently use any mediation" and list "Clonipen [sic] 0.5 mg, Inderal 120 mg." The application indicates "no" under items 18.1. "neurological disorders" and 18.m. "mental disorders." "Notes" indicate "Benign essential tremor-treated with Inderal [propanolol] and Klonopin [clonazepam].

8/28/96 - A letter from the FAA Southwest Regional Flight Surgeon to the pilot states "information provided this office indicates a reasonable basis for re-examining your ability to meet the medical standards...this office has been advised that you were recently involved in an aircraft accident at which time you appeared to be experiencing medical problems. ... Review of you airman medical file reveals you have a history of benign essential tremor requiring the use of medications, Inderal and Klonopin. To assist us in our evaluation of your case, it will be necessary that ... you provide this office with a current report from your treating physician as pertains to your history of benign essential tremor. You are reminded that your operation of aircraft as pilot in command after receipt of this letter may constitute a violation of Federal Aviation Regulation 61.53."

9/10/96 - A letter from the FAA Southwest Regional Fight Surgeon to the pilot states "we have received your letter dated September 2, 1996, and will temporarily hold your medical file in pending status until all the information previously requested is received. Enclosed are several written statements from individuals who reported your behavior following the aircraft incident of August 19, 1996. As you will notice, witnesses report that you appeared to be impaired, with shaking, with slurring speech, and at one point you fell off the wing of the aircraft after returning to the cockpit. ..."

9/23/96 - A letter from the pilot's neurologist to the FAA Southwest Regional Flight Surgeon notes that the pilot had been treated "for familial tremor (aka benign essential tremor) since 1991" and that he has "a head tremor, without no [sic] detectable tremor of the extremities. The tremor is not disabling and is well-controlled by mediations. He is currently taking Propanolol ER, 120 milligrams, 3-5 orally per day, as well as Clonazepam, 0.5 milligrams, 1-4 orally per day. The amount of medication varies daily with the severity of symptoms, situations, etc. he has had no significant side effects from these medications. His condition is stable, with no change in medications or dosages thereof within the last two years."

10/30/96 - A letter from the FAA Aeromedical Certification Division to the pilot noted in part "We have recently received information from the regional office which indicates a reasonable basis to believe that you may not meet the medical standards ... you are requested to have your attending physicians, treating hospitals, or other agencies forward to this office a complete report of your medical condition requiring the use of disqualifying medication (clonazepam) and results of a current, detailed neurological evaluation and a current cardiovascular evaluation in accordance with the enclosed specifications to include results of a current 24-hour Holter monitor test. ... We cannot consider you qualified to use your medical certificate at this time. ..."

7/26/00 - Application for Airman Medical Certificate indicates "yes" under item 17.a. "Do you currently use any medication" and list only "Lipitor 10 mg per day." The application indicates "no" under items 18.1. "Neurological disorders" and 18.m. "mental disorders." "Notes" indicate "Essential tremor of head and neck. Has not used Clonipen [sic] or propanolol in over six months." "Other test given" notes "not issued due to fasting glucose 145."

7/31.00 - A letter to the FAA from the pilot's AME notes in regard to the pilot that "on 7/26/00 I issued a Class III, then I asked him to surrender it, which he did the following week. This was because lab drawn on the initial visit was reported later and included FBS 145."

12/29/00 - A letter from the FAA Aeromedical Certification Division to the pilot noted in part "we have reviewed your application for medical certification and note a history of head and neck tremor. Before we can determine your eligibility for medical certification, we require, for our review, copies of all medical records from the hospitals, consultants, medical boards, and attending physician regarding your head and neck tremor ... Also please submit a current neurological and cardiovascular evaluation in accordance with the enclosed specifications, to include a current twenty-four hour Holter monitor, as previously requested in our letter of October 30, 1996. In addition, due to your possible diabetes, please submit a report from your treating physician to include ..."

The following pertinent medical information was extracted by NTSB Medical Officer from the medical recor

NTSB Probable Cause

The private pilot's failure to maintain aircraft control during a go-around. Contributing factors were the private pilot's impairment due to drugs, the pilot-rated passenger's lack of experience in the airplane, and the prevailing gusty crosswind conditions.