NTSB Factual Report

HISTORY OF FLIGHT

On August 14, 2008, at 1026 eastern daylight time, a Beech model 58TC (Baron), N715TB, was destroyed during an in-flight collision with terrain and post impact fire about 0.4 miles west of Union County Airport (MRT), Marysville, Ohio. The flight was being conducted under Title 14 Code of Federal Regulations Part 91. An instrument flight rules (IFR) flight plan was on file, but had not been activated at the time of the accident. Visual meteorological conditions prevailed. The pilot sustained fatal injuries. The flight had departed from runway 9 (4,218 feet by 75 feet, asphalt) at MRT just prior to the accident. The intended destination was Fulton County Airport (FTY), Atlanta, Georgia. (Unless otherwise noted, all times in this report are eastern daylight time based on a 24-hour clock.)

Prior to the flight, the pilot reportedly attended a business meeting that ran long. He had initially intended to depart between 0900 and 0930. He also had a physician appointment that morning before the flight. (Refer to the medical information section of this report for further details.)

The pilot accessed the Direct User Access Terminal System (DUATS) at 0900 on August 14th. He filed an IFR flight plan from MRT to FTY, with a proposed departure time of 0930. He contacted the fixed base operator to request the airplane be pulled out of the hangar and fueled for a 0945 departure. The airplane was subsequently fueled about 0920. The airport manager recalled that he saw the pilot at the airplane putting some bags in the baggage compartment and starting a pre-flight inspection. He noted that after engine start-up, the pilot taxied to runway 9. He commented that the engines sounded fine.

A flight instructor conducting touch-and-goes in the traffic pattern noted that the accident airplane taxied to runway 9, where it appeared to the instructor that the pilot completed a normal run-up. The instructor's airplane was on a downwind leg in the traffic pattern, with one airplane ahead of his position. The accident pilot subsequently inquired if he had sufficient spacing to depart ahead of that airplane, which was abeam the approach end of the runway at that time. The pilot of that airplane reported that he did, and the accident pilot subsequently taxied onto the runway and took off.

The flight instructor stated that he and his student had just completed a landing and throttled up for take off when he heard a pilot transmit "Aircraft on [runway] 9, I need the runway." The pilot repeated the radio call and the flight instructor replied, "We are on the roll." During initial climb after takeoff, the flight instructor reported that the accident airplane came into view through the rear window. The accident airplane was near the approach end of runway 9 in a 45-degree bank, with the nose pitched down about 15 degrees. The airplane appeared to overshoot the extended runway centerline as it turned final. The flight instructor noted the accident airplane's wings leveled south of the runway centerline. The airplane then "pitched up suddenly and rolled sharply to [the] left." The airplane rolled inverted and struck the ground. A post impact fire ensued.

The student pilot stated that they had just completed a short field landing and throttled up for takeoff when the accident pilot transmitted, "I need the runway" or words to that effect. Although the pilot did not state what airport he was at or his tail number, she recalled thinking he might be referring to them since they were on the runway. The flight instructor radioed that they were on the roll. She reported that they lifted off "several seconds" after the flight instructor's reply. While they were climbing out, the accident pilot then made a second call similar in nature to the first. She did not witness the accident sequence.

A witness located approximately 1 mile north-northwest of the airport reported that the accident airplane flew almost directly over his position on a southbound course. He stated that it appeared to be in straight flight; however, he was unable to tell if it was descending. He added that the landing gear was down and the engines sounded like they were running fine. The witness recalled a "bulge" on the right side of the airplane, which he thought might be an open door. He added that there was nothing else unusual about the airplane.

The airplane came to rest upright on a south-southeast heading. The post impact fire consumed approximately the forward two-thirds of the fuselage and portions of both wings.

PERSONNEL INFORMATION

The pilot, age 33, held a private pilot certificate with single engine, multi-engine, and instrument airplane ratings. He was issued a first-class airman medical certificate with no limitations on February 10, 2006. His most recent flight review was completed on November 2, 2007. An instrument proficiency check was also completed on that date.

The pilot's logbook and additional notations of pilot flight time were reviewed. The pilot's last logbook entry was dated May 18, 2007. According to the logbook, he had accumulated 1,410.5 hours total flight time, with 40.7 hours of multi-engine flight time. The logged multi-engine flight time included 35.0 hours in the accident airplane, and 5.7 hours in a Beech model 95 airplane. A separate listing accompanying the logbook noted 11 flights between May 29, 2007 and October 15, 2007, totaling 44.5 hours. There was no indication of the type of aircraft flown. Accordingly, the pilot's total flight time was approximately 1,455 hours, with at least 40 hours of multi-engine flight time.

However, on his most recent airman medical certificate application, the pilot reported a total flight time of 2,200 hours, with 150 hours flown within the past 6 months.

AIRCRAFT INFORMATION

The accident airplane was a 1980 Beech model 58TC (Baron), production serial number TK-127. At the time of the accident, it was owned by Corporate Roof Management Systems Ltd. of Dublin, Ohio, and registered as N715TB. The airplane was a six-place, twin-engine aircraft, with a retractable tricycle landing gear configuration.

The airplane was powered by two Teledyne Continental Motors TSIO-520-WB(1) engines. The left and right engine serial numbers were 518467-H and 822617-R, respectively. The engines were six cylinder, turbo-charged, reciprocating engines rated to develop 325 horsepower.

The most recent annual inspection was completed on August 1, 2008, at a total airframe time of 5,218 hours. The left engine had accumulated 1,378 hours since overhaul, and the right engine had accumulated 788 hours since being rebuilt. There were no maintenance entries subsequent to the annual inspection.

METEOROLOGICAL CONDITIONS

Conditions recorded at the Ohio State University Airport (OSU), located about 15 miles southeast of MRT, at 1053 were: Winds from 330 degrees at 7 knots; visibility 10 miles; clear skies; temperature 23 degrees Celsius; dew point 14 degrees Celsius; altimeter 29.88 inches of mercury.

AIRPORT INFORMATION

Union County Airport (MRT), Marysville, Ohio, was a non-towered airport that consisted of a single paved runway. The airport elevation was 1,021 feet. Runway 9 - 27 was 4,218 feet long by 75 feet wide, and constructed of asphalt. Both runways were served by Precision Approach Path Indicators (PAPI) set to a 4-degree glide path. A standard left traffic pattern was applicable to both runways. A parallel taxiway was located north of the runway. An open grass area about 250 feet wide was located south of the runway.

The airport was bordered on the west by a two-lane roadway. There was a rising embankment between the roadway and the runway. The approach to runway 9 consisted of a soybean field immediately west of the roadway. The elevation of the level soybean field was approximately 25 feet below the elevation of the runway. Additional agricultural fields bordered the soybean field to the north, and a residential-commercial area bordered the airport to the north.

WRECKAGE AND IMPACT INFORMATION

The accident site was located in a soybean field west of the airport. The airplane was located 0.15 nautical miles southwest of the runway 9 threshold. It came to rest upright on an approximate magnetic heading of 144 degrees. The magnetic bearing from the site to the runway threshold was 062 degrees.

The main wreckage consisted of the fuselage, empennage, wings, and right engine. The left engine separated from the airframe and came to rest approximately 26 feet east-northeast of the main wreckage. The propellers separated from the engines at the crankshafts and were located about 90 feet southwest of the main wreckage. A ground impact mark about 18 inches long and 3 inches deep was located approximately 128 feet southwest of the main wreckage.

The forward portion of the fuselage was destroyed by impact forces and the post impact fire. Both the right and left wings exhibited fire damage over their entire spans. The right aileron remained attached to the wing. The inboard portion of the left aileron remained attached to the wing. The outboard portion was consumed by the fire. Aileron cable continuity to the cockpit area was confirmed. The flaps were separated from the wings. The right flap actuator extension corresponded to a 20-degree flap deflection.

The right engine was dislocated from the airframe and came to rest upright adjacent to its normal position. The engine exhibited damage consistent with impact forces and post impact fire damage. The left engine had separated completely from the airframe. The engine exhibited damage consistent with impact forces. Teardown inspections of both engines did not reveal any anomalies attributable to a pre-impact malfunction.

Both propellers separated from their respective engines at the crankshaft, aft of the propeller flange. The right and left propeller assemblies were embedded into the ground about 8 inches. They were face down and spaced approximately 38 feet apart. The propeller blades exhibited bending and twisting. The spinners were torn and deformed around the propeller hubs. The crankshaft fracture surfaces appeared consistent with overload failures.

The empennage was intact. The rudder and elevator remained attached to their respective stabilizers and were free to move. Control continuity was confirmed from the rudder and elevator to the cockpit area.

The right wingtip fuel tank cap and filler neck were separated and located in the debris path. The post impact fire had consumed the surrounding wing structure. The cap and filler neck appeared intact and without fire damage. The cap was observed in the open position at the time of the on-scene investigation. The cap was attached to the filler neck by the retainer strap. The cap locking mechanism functioned properly when examined on-scene. The anti-siphon valve was intact.

The left wing tip had separated from the airframe. It exhibited damage consistent with impact forces. The wingtip fuel tank cap was locked in place at the time of the on-scene investigation.

The cockpit door was destroyed by the post impact fire. Both the forward and aft utility doors were damaged by impact forces and post impact fire. The forward utility door was destroyed by the post impact fire. The handle and latch mechanism were observed in the baggage area. The aft utility door appeared intact. The door was discolored consistent with the fire damage. The aft utility door latches were in the open position. The lock/unlock handle on the forward edge of the door was in the extended (unlocked) position. The latch plate located on the forward edge of the door, which engaged the locking pin from the forward door, was separated from the aft door assembly. (See the Tests and Research section of this report for further information.)

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy of the pilot was conducted by the Licking County Coroner's Office, Newark, Ohio. The cause of death was attributed to internal injuries due to blunt force trauma sustained in the accident.

The Federal Aviation Administration Civil Aero Medical Institute (CAMI) toxicology report for the pilot indicated the presence of orphenadrine in blood and urine samples. No ethanol or carbon monoxide was detected. The samples were negative for all other substances.

The FAA toxicology laboratory did not quantify the level of orphenadrine, which indicated that the substance was detected at very low levels (below the calibration curve for the substance, in this instance at 12.5 ng/mL).

Review of the pilot's personal medical records documented a history of a sudden episode of severe neck pain in November 2007, which was since his most recent medical certificate application. This episode was treated with prednisone, oxycodone, orphenadrine, and physical therapy. The records documented a follow-up physician visit in July 2008, in which the pilot noted improvement, but not a resolution, of the symptoms. On October 14, 2008, the date of the accident, the pilot sought chiropractic treatment for continued neck pain. On that date, the pain was noted as having an average intensity of 6 out of 10, and the range of motion of his neck was substantially limited. He received a chiropractic adjustment during that visit.

TESTS AND RESEARCH

The utility door installation is located on the right side of the fuselage, aft of the wing. It consists of a forward and an aft door that are hinged on the forward and aft door edges, respectively. When both doors are open they provide about a 4-foot wide access to the cabin area. The aft door is designed to be closed first. It is secured by latches that engage the upper and lower doorjambs. A lever located at the forward, jamb-area of the aft door engages and disengages the latches. When locked, the latch nests flush with the edge of the door. When unlatched, the lever extends into the forward door area and prevents it from closing completely. The forward door is secured by a deadbolt that extends into the aft door. The aft door is reinforced in that area by the striker plate. The forward door is also secured by pins that extend into the upper and lower doorjambs.

The airplane flight manual instructed pilots to return for landing in a normal manner if a door came open during flight. It added that a door will trail in a position approximately 3 inches open, but the airplane's general flight characteristics will not be affected. However, it did note that the airplane's rate of climb will be reduced when operating with a door open.

The airplane manufacturer issued a Safety Communique in October 1995 regarding door and fuel cap security. The communique informed pilots that airplanes have been flown safely with doors open and fuel caps unsecured. It reminded pilots to fly the airplane in a normal manner, while maintaining airspeed for safe flight. It suggested that the pilot land as conditions permit. It was not determined whether the pilot was aware of the Safety Communique.

NTSB Probable Cause

The pilot's failure to maintain sufficient airspeed during the base to final turn resulting in an aerodynamic stall.