NTSB Factual Report

HISTORY OF FLIGHT

On July 16, 2012, about 1905 eastern daylight time, a Beech A23, N8771M, was substantially damaged following a collision with terrain in Laytonsville, Maryland. The private pilot received minor injuries and the flight instructor was fatally injured. The airplane was registered to a corporation and was operated by an individual under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed and a Washington, DC, special visual flight rules flight plan was filed for the local flight. The flight originated from Davis Airport (W50), Laytonsville, Maryland, about 1845.

According to the pilot, the purpose of the flight was to prepare for a flight review with the flight instructor. The pilot performed a preflight inspection and fueled the airplane prior to takeoff with no anomalies noted. They performed two takeoffs and landings prior to the accident. After each landing they would perform the after landing checklist, then prior to takeoff, they would perform the before takeoff checklist. During the check, the pilot verified that the flaps were retracted for takeoff and that the left fuel tank was selected with the fuel selector.

During the final takeoff, the pilot applied power and released the brakes. The airplane rolled down the runway, lifted off the ground, and then settled back onto the runway. The pilot stated that he continued to apply full power but the airplane “did not have nearly as much lift” as the previous takeoffs. As the airplane continued to climb, the pilot initiated a turn to the right in order to avoid striking trees off the end of the runway. The flight instructor then took the flight controls as the right turn became steeper. The airplane then entered a spin and impacted the ground.

According to witnesses, the pilot applied full engine power in order to take off on runway 26. One witness stated that it seemed the airplane was "having difficulty climbing out of ground effect." The airplane continued the takeoff, climbed to about 150-200 feet above ground level, banked right, and entered a stall and subsequent spin until it impacted the ground. One witness stated that the airplane would not be able to clear the trees at the end of the runway. Another witness noted that the engine "backfired" and that he heard it lose power prior to impacting the ground.

According to an employee at the airport, he topped off the fuel tanks prior to the accident flight. He then observed the airplane perform several successful takeoffs and landings prior to the accident.

The wreckage came to rest approximately 425 feet beyond and to the right of the departure end of runway 26.

PERSONNEL INFORMATION

According to Federal Aviation Administration (FAA) records, the pilot, age 83, held a private pilot certificate with ratings for airplane single-engine land, multiengine land, and instrument airplane. His most recent FAA third-class medical certificate was issued September 24, 2010, and at the time of the examination the pilot reported 2,300 total hours of flight experience. The medical certificate was issued with two restrictions: must wear corrective lenses and must wear hearing amplification. According to the pilot's logbook, he accumulated 2,319.2 total hours of flight time. His most recent flight review occurred in July 2010. He accumulated 1.9 hours of flight time in the past 90 days in the accident airplane.

According to FAA records, the flight instructor, age 79, held a commercial pilot certificate with ratings for airplane single-engine land, single-engine sea, multiengine land, glider, and instrument airplane. In addition, he held a flight instructor certificate for airplane single-engine, multiengine, instrument airplane, gliders, as well as an advanced ground instructor certificate and an instrument ground instructor certificate. His most recent FAA third-class medical certificate was issued June 12, 2012, and at the time of the examination the pilot reported 18,000 total hours of flight experience. At the time of this writing no pilot logbooks had been located.

AIRPLANE INFORMATION

According to FAA records, the airplane was manufactured in 1964, and was registered to a corporation in 2002. It was a low-wing, fixed, tricycle gear airplane that was equipped with a Continental Motors IO-346-A series engine rated at 165 horsepower. The most recent annual inspection was performed on September 13, 2011, and at that time, the airplane had accumulated 1,989.66 hours of total flight time.

METEOROLOGICAL INFORMATION

The 1855 recorded weather observation at Gaithersburg, Maryland (GAI), located approximately 5 nautical miles south of the accident location, included calm wind, clear skies, temperature 31 degrees C, dew point 23 degrees C, and an altimeter setting of 29.89 inches of mercury.

AERODROME INFORMATION

Davis Airport was located about three miles north of Laytonsville, Maryland, at 630 feet elevation. The asphalt runway was 2,005 feet long, 25 feet wide, and oriented 08/26. The Airport Facility Directory noted that there were trees at both ends of the runway and a glide angle of four degrees was needed to clear the trees.

WRECKAGE AND IMPACT INFORMATION

The main wreckage came to rest in an area of dense underbrush. The coordinates of the main wreckage were 39:14.545 N, 077:09.274 W, and the first indication of ground contact was about 45 feet east of the main wreckage.

A note pad found in the fuselage indicated the date, July 16, and a start tach time of 1,993.08 for the flight. The tachometer discovered in the airplane indicated a tach time of 1,993.37 hours.

There were no pre-impact anomalies noted with the airframe. All components of the airplane were located within the area of the main wreckage. The right wing tip was located next to the initial impact ground scar approximately 45 feet from the main wreckage.

Flight control cable continuity was established from the cockpit controls to the control surfaces. Flight control cable continuity was observed to be intact from the cockpit control connection point to the empennage flight controls. The aileron flight controls were observed to be intact from the cockpit flight controls to the left and right aileron bell cranks. Rudder control continuity was confirmed from the cockpit area to the rudder. Flap control continuity was established from the flap control handle to the left and right flap turnbuckles.

The left wing remained attached to the fuselage and was displaced slightly aft. The forward section of the left wing root was separated from the fuselage and the aft portion of the wing root was crushed into the fuselage. The outboard six feet of the wing was crushed in the aft and positive direction. The wing tip and pitot tube remained attached to the left wing. The left main landing gear remained attached to the wing. The outer leading edge, next to the wing tip attachment, was buckled and vegetation debris was found in the area of the buckle. The aileron remained attached to the wing at all attach points. The flap remained attached to the wing via the inboard flap attachment and the outboard attachment point. The flap control rod was separated from the flap torque tube.

The left wing fuel tank was breached and empty. There was a small area of blight on the vegetation under the left wing root. The left wing fuel cap seals were examined with no anomalies noted. The left wing fuel vent was clear and free of debris.

The stall warning indicator was located on the leading edge of the left wing. Stall warning continuity was confirmed with a multimeter through the switch housing.

The right wing remained attached to the fuselage. The leading edge of the right wing exhibited brown scoring/markings in the left to right direction. The outboard three feet of the right wing was damaged in the aft and positive direction. The forward section of the right wing root was crushed toward the fuselage. The aft section of the right wing root was separated from the fuselage. The right aileron remained attached to the right wing. The right flap remained attached to the wing via the inboard and outboard flap attachment points and was displaced toward the fuselage about 4-6 inches. The flap control rod was separated from the flap torque tube. The right main landing gear remained attached to the right wing. The right wheel was displaced to the inboard side of the right main landing gear strut.

The right wing fuel tank was filled to about a quarter inch above the bottom of the tab. It was reportedly full of fuel when the first responders arrived. The right wing fuel cap seals were examined with no anomalies noted. The right wing fuel vent was clear and free of debris. A fuel sample was taken from the right wing and no contaminants were noted.

The forward area of the fuselage was bent and buckled in several places on both the left and right sides. The right side of the fuselage forward of the right wing was buckled. The roof of the fuselage was cut and removed by first responders. Both front seats had separated from the seat tracks. Three of the four seat mounts on both the left and right front seats were spread. The seatbelts remained attached to their respective attachment points. Both the right front and left front seat belt webbing did not exhibit any deformation or stretching. The airplane was not equipped with shoulder harnesses.

The airplane fuel tank capacity was 59.8 gallons, of which 58.8 gallons were usable. The left fuel filler cap was installed with the latch closed. The left fuel tank output line was found separated at the fuselage side wall. The right tank fuel filler cap was installed with the latch closed. The fuel selector valve was located between the left front and right front seats along the forward edge of the seats. The fuel selector was discovered in a mid-range position between the left and right fuel tanks. Fuel system continuity was confirmed from the left tank through a void at the wing root to the fuel selector and from the right tank to the fuel selector. The fuel selector was tested with no anomalies noted. When the fuel selector was placed to the center position, similar to where it was found after the accident, fuel would not flow through the fuel selector. In addition, there was a witness mark from the fuel selector knob on the plate that covered the fuel selector. The mark was consistent with the center position indication that the fuel selector was found in.

The fuselage exhibited witness marks that were in the vicinity of the inboard edge of the flap. The scoring was in the vicinity of the zero degree flap position. In addition, the flap selector was discovered in the zero degree (retracted) position.

The empennage was displaced to the right of the longitudinal axis and was separated at the aft bulkhead. It was separated on the left side but remained attached to the fuselage on the right side. It was displaced about 80-90 degrees to the right of the longitudinal axis. The horizontal stabilizers remained attached to the rear empennage. The left side of the horizontal stabilizer was displaced in the forward direction and the right horizontal stabilizer was displaced in the aft direction. The vertical stabilizer remained attached to the rear empennage and the rudder remained attached to the vertical stabilizer. The stabilizer trim tab remained attached to the trailing edge of the stabilizer and was bent in the positive direction. The leading edge of the horizontal and vertical stabilizer remained undamaged. The left side of the empennage was dented inward in the vicinity of the left stabilizer.

The engine remained attached to the engine mounts which remained attached to the firewall on all but one mount leg. It was displaced down and to the right of the longitudinal axis of the airplane. There were oil stains on the vegetation under the engine noted after the wreckage was moved. The engine controls were found in the full forward positions.

The engine remained intact. The propeller remained attached to the crankshaft propeller mounting flange. The muffler remained attached to the exhaust system but was impact damaged. Both magnetos remained attached to the engine. The vacuum pump remained attached. The oil filter was attached to the accessory section.

The top spark plugs were removed from the cylinders and the fine wire electrodes exhibited normal wear and color when compared to the Champion fine wire spark plug inspection card.

The engine crankshaft was rotated by hand via the propeller and continuity was confirmed from the propeller to the accessory drive section of the engine. Cylinder valve train continuity was observed to be intact with no anomalies noted. Compression and suction were confirmed on all four cylinders using the thumb compression method.

The shower of sparks ignition system remained attached to the firewall.

All cylinders were borescoped and no anomalies were noted. The valves remained intact and no anomalies were noted.

No fuel was discovered when the main fuel line and the return fuel line were disconnected from the engine. The fuel pump drive remained attached to the engine, and rotated freely with no anomalies noted. The fuel manifold was disassembled. The plunger gasket exhibited a small amount of dry rot. The fuel manifold screen was free of debris and fuel was present in the manifold. The fuel injectors were removed. The Nos. 1, 3, and 4 injectors were clear with no obstructions. The No. 2 injector was partially blocked.

The propeller was a two bladed Sensenich fixed pitch propeller. The propeller blades displayed leading edge nicks and gouges and chordwise scratching on the blade back. One blade was bowed aft.

MEDICAL AND PATHOLOGICAL INFORMATION

The Office of the Chief Medical Examiner for the State of Maryland performed the autopsy on the flight instructor. The autopsy report indicated that the flight instructor died as a result of “multiple injuries.”

The FAA’s Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of the flight instructor. Fluid and tissue specimens from the flight instructor tested negative for carbon monoxide, cyanide, and ethanol. However, the toxicological test did test positive for acetaminophen and rosuvastatin in the urine, desmethylsertraline, diphenhydramine, glipizide, and sertraline in the liver, and desmethylsertraline, glipizide, and piolitazone in the blood.

In addition, according to a postmortem clinical report on the flight instructor, 34 (mg/dl ) Glucose was detected in Vitreous, 1150 (mg/dl ) Glucose was detected in Urine, and 8.7 (%) Hemoglobin A1C was detected in Blood.

Sertraline (Zoloft®) is a prescription selective serotonin reuptake inhibitor (SSRI). It is used as an antidepressant.

Desmethylsertraline is the predominant metabolite of the antidepressant sertraline, Zoloft®. While it is an active metabolite, it is substantially less active than sertraline.

Diphenhydramine (Benadryl® or Sominex®) is an over-the-counter sedating antihistamine used to treat allergies and Sominex® is marketed as a nonprescription sleep aid.

Glipizide (Glucotrol®) is an oral blood-glucose-lowering drug of the sulfonylurea class that stimulates the release of insulin from the pancreas. The medication is used to treat type 2 (non-insulin dependent) diabetes and may cause hypoglycemia.

Pioglitazone (Actos®) is an oral antidiabetic agent that acts primarily by increasing uptake of glucose by peripheral organs and decreasing glucose production by the liver. It is used in the management of type 2 diabetes mellitus.

Rosuvastatin (Crestor®) is a prescription lipid lowering agent used to treat elevated blood lipids and elevated cholesterol.

According to the FAA, on the flight instructor’s most recent FAA medical certificate application, he did not report using any medication. In addition, he reported that he did not have any type of diabetes.

The pilot was asked about the physical condition of the flight instructor and stated that he did not observe the flight instructor under any duress, showing lack of alertness, or any health issues.

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NTSB Probable Cause

The pilot’s failure to ensure that the fuel selector handle was correctly positioned, which resulted in an interruption of fuel to the engine and a loss of engine power during the takeoff, which necessitated a turn away from the trees at the end of the runway and the subsequent stall.