NTSB Factual Report

HISTORY OF FLIGHT

On December 11, 2015, about 1422 eastern standard time, a Beech A36, N72054, was destroyed when it impacted trees and terrain shortly after takeoff from Nemacolin Airport (PA88), Farmington, Pennsylvania. The private pilot and two passengers were fatally injured. The airplane was privately owned and operated under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the personal flight, which was destined for Montgomery County Airport (GAI), Gaithersburg, Maryland.

PA88 was located on the property of the Nemacolin Woodland Resort. A witness who was staying at the resort, who viewed the airplane from his hotel room which was located on the northwest side of the runway reported that, after takeoff from runway 23, the airplane's landing gear retracted, and the airplane appeared to be departing the area; however, the airplane continued to turn as if entering the downwind leg of the traffic pattern. The landing gear extended, and the airplane began to descend. The airplane continued to descend in a turn consistent with a left base for runway 23; the witness then lost sight of the airplane behind terrain. Shortly after, he observed smoke. Another witness who was standing about 2,500 ft southeast of the runway saw the airplane pass overhead with the landing gear down. He stated that the airplane was "pretty low" and that the engine sounded normal. He saw the airplane bank to the left, and then he lost sight of it behind buildings; he then heard an impact and saw flames and smoke.

An onboard GPS recorded data for the accident flight. The recording began at 1415:57 near the airport parking area. The airplane subsequently taxied to the end of runway 23 for takeoff. Recorded GPS altitude at this time was about 1,975 ft. The takeoff roll began at 1420:18. At 1421:00, at a GPS altitude of 2,184 ft and about 2,500 ft from the departure end of the runway, the airplane began a left, climbing turn. The turn continued, and the airplane reached a maximum recorded altitude of 2,457 ft at 1421:36. At this time, its position was consistent with a left downwind for runway 23. The airplane descended as it continued the downwind leg, then began a left turn about 1422. Shortly thereafter, the airplane descended through 2,150 ft at 69 knots groundspeed. The last recorded data point was at 1422:22.

Figure 1. Plotted GPS Data – Complete Accident Flight.

Figure 2. Plotted GPS Data – End of Accident Flight.

About 1423, landscaping personnel called the resort's security dispatch and reported the accident. Security personnel arrived to find the airplane fully engulfed in flames and one passenger laying outside of the airplane on the golf course.

The passenger, who was severely burned during the accident, had egressed from the airplane by himself and was pulled from the accident site by resort guests. He advised first responders that his father (who was flying the airplane) and his friend were onboard the airplane. He remembered taking off from the runway, the door opening and feeling wind, and then being surrounded by flames. He was transported to a burn center and succumbed to his injuries about 2 days later.

PERSONNEL INFORMATION

According to Federal Aviation Administration (FAA), and pilot records, the pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane, and a commercial pilot certificate with ratings for helicopter and instrument helicopter. His most recent application for an FAA third-class medical certificate was dated February 22, 2014. The pilot had accrued about 3,261 total hours of flight experience, of which 2,663 hours were in the accident airplane make and model.

AIRCRAFT INFORMATION

According to FAA airworthiness records and airplane maintenance records, the airplane was manufactured in 1984. The airplane's most recent annual inspection was completed on November 11, 2015. At the time of the inspection, the airplane had accrued about 4,448.5 total hours of operation, and the engine had accrued about 1,158.8 total hours of operation since major overhaul.

METEOROLOGICAL INFORMATION

The 1435 reported weather at Garrett County Airport (2G4), Oakland, Maryland, located 17 nautical miles southeast of the accident site, included wind from 250° at 11 knots gusting to 19 knots, 10 miles visibility, broken clouds at 1,300 ft, temperature 11°C, dew point 8°C, and an altimeter setting of 29.95 inches of mercury.

AIRPORT INFORMATION

PA88 was located about 1 mile east of Farmington, Pennsylvania. It was classified by the FAA as a privately owned, private-use airport. The airport elevation was 2,010 ft above mean sea level and the asphalt runway was configured in a 5/23 orientation. The runway measured 3,980 ft long by 49 ft wide. The runway 23 threshold was displaced 935 ft due to trees off the approach end of the runway. The runway was equipped with medium intensity runway edge lights, and a precision approach path indicator system which, at the time of the accident, was disabled.

FLIGHT RECORDERS

The accident airplane was equipped with a handheld Garmin GPSMAP 39x/49x series GPS.

The unit had suffered extreme thermal damage, but an internal examination revealed the non-volatile memory chip was intact, and data from the accident flight was extracted.

WRECKAGE AND IMPACT INFORMATIOJN

The airplane came to rest in a heavily wooded area located next to a golf course.

Examination of the accident site revealed that the airplane had broken apart after striking trees in a left-wing-down, nose-low attitude. During the impact sequence, the main cabin portion of the airplane traveled about 152 ft before impacting the forest floor and coming to rest, facing the opposite direction of travel, with the aft fuselage and empennage lying behind it in an inverted position. The engine, left outboard wing, right wing flap, right main landing gear, and engine cowlings were all separated from their mounting positions and were strewn throughout the accident site. Further examination also revealed the presence of propeller strikes on broken tree branches and tree trunks that littered the ground, along with areas of burned underbrush and fire-damaged trees.

Examination of the wreckage revealed that the landing gear was in the down position, and all major portions of the airplane's structure were present at the accident site. No evidence of any preimpact failure of the airplane structure was discovered.

Examination of the flight control system revealed no evidence of any preimpact failure or malfunction, and flight control continuity was established from the flight control surfaces to the rudder pedals and control wheels through breaks in the system consistent with overstress failure.

Examination of the fuel system revealed that all four fuel caps were closed and locked, and the fuel selector valve was in the left main tank position.

Examination of the propeller and engine also revealed no evidence of any preimpact failure or malfunction that would have precluded normal operation. The propeller remained attached to the propeller flange and exhibited a circumferential fracture just aft of the propeller flange. All three blades exhibited S-bending, twisting, and chordwise scratching. Oil was present in the rocker boxes and oil sump, and the oil filter was absent of debris. Crankshaft and valve train continuity was confirmed, and compression and suction were observed on all six cylinders.

Examination of the interior of the cylinders with a lighted borescope did not reveal evidence of any preimpact damage to the piston domes, cylinder walls, or valves. Both magnetos were functional and produced spark at all towers.

Examination of the remains of the utility doors, which were located on the aft right side of the fuselage, and the forward cabin door, which was located on the forward right side of the fuselage, revealed that most of the door structures had been burned away. Further examination revealed that the locking mechanisms were present and did not show any evidence of malfunction or failure.

Examination of the forward cabin door revealed that the upper latching mechanism (hook) was not fully extended, and the slot in the upper fuselage frame that the hook engaged when the door was closed showed no evidence of tear-outs. Further examination also revealed that the door handle mechanism was not fully in the locked position; the lower aft latch pin, which rode in a guide inside the lower aft portion of the forward cabin door and engaged a receptacle in the lower door sill, was missing.

MEDICAL AND PATHOLOGICAL INFORMATION

According to FAA airman medical records, during his last medical examination, the pilot reported that he had no chronic medical conditions and was on no medications.

According to the report of the autopsy performed by Cyril H. Wecht and Pathology Associates, Inc., Pittsburgh, Pennsylvania, the cause of death was multiple blunt force injuries and the manner of death was accident. The autopsy identified minimal coronary artery disease with about 10-15% stenosis. The heart weight was not provided, but the right ventricular wall was described as 0.4-cm thick, the left ventricular wall as 1.5-cm thick, and the septum as 1.3-cm thick. Average for these thicknesses is 0.3 cm, 1.23 cm, and 1.23 cm, respectively. The remainder of the examination was unremarkable.

Toxicology testing performed at the request of the medical examiner by NMS Labs identified caffeine and 0.310 ug/ml of amphetamine in the pilot's blood.

Toxicology testing performed by the FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, identified amphetamine at 0.347 ug/ml in blood and 1.828 ug/ml in urine, as well as phenylpropanolamine in urine, but not in blood.

Amphetamine is a Schedule-II controlled substance that stimulates the central nervous system. It is available by prescription for the treatment of attention deficit disorder and narcolepsy. It carries a boxed warning about its potential for abuse and has warnings about an increased risk of sudden death and the potential for mental health and behavioral changes. Commonly marketed names include Adderall, Dexedrine, and Vyvanse. After a single 30 mg oral dose, early blood levels averaged 0.111 ug/ml and average blood levels in adults using the long acting prescription orally for a week were about 0.065 ug/ml. Generally, levels above 0.2 are the result of misusing amphetamine to maximize its psychoactive effects.

Amphetamine is also prepared and used as a street drug, often by snorting, inhaling, or injecting. Street preparations may begin with phenylpropanolamine, which may then contaminate the final product.

In the early phase, amphetamine misusers may experience a combination of euphoria, excitation, exhilaration, rapid flight of ideas, increased libido, rapid speech, motor restlessness, hallucinations, delusions, psychosis, insomnia, reduced fatigue or drowsiness, increased alertness, a heightened sense of well-being, stereotypes behavior, feelings of increased physical strength, and poor impulse control. Heart rate, blood pressure, and respiratory rate increase, and they may have palpitations, dry mouth, abdominal cramps, twitching, dilated pupils, faster reaction times, and increased strength. As the initial effects wear off, users commonly experience dysphoria, restlessness, agitation, and nervousness; they may experience paranoia, violence, aggression, a lack of coordination, delusions, psychosis, and drug craving.

Phenylpropanolamine is a sympathomimetic also in the amphetamine class that was once available in over-the-counter preparations for treating colds. However, it also increases heart rate and blood pressure, and its availability in the United States was discontinued in 2000. It remains available as a veterinary medicine.

ADDITIONAL INFORMATION

Materials Laboratory Examination

On May 4, 2016, the latching mechanism for the door of the airplane was examined in the NTSB Materials Laboratory. Deposits were observed on the external surfaces of the latching mechanism that were consistent with soot and other combustion products. Using a 5x to 50x stereo-zoom microscope, the fracture surfaces were examined. The fracture surface features were consistent with overstress related to incipient melting.

Pilot's Operating Handbook - Forward Cabin Door

The airplane's pilot's operating handbook (POH) stated that, when closed, the spring-loaded outside cabin door handle would fit into a recess to create a flat, aerodynamically clean surface. It could be locked from the outside with a key to secure the airplane.

The door could be opened from the outside by lifting the handle out of the recess and pulling until the door opened.

When closing the door from the inside of the airplane, the door handle was moved to the open position. In this position, the latch handle would be free to move about 1 inch in either direction before engagement of the locking mechanism. The door could then be grasped and firmly pulled closed, and the handle could then be fully rotated counterclockwise into the locked position. When the door was properly locked, the door latch handle would be free to move about 1 inch in either direction.

The POH noted that, when checking the door latch handle, "do not move it far enough to engage the doorlatch release mechanism." The POH also advised to press firmly at the top rear corner of the door and that, if any movement of the door was detected, to completely open the door, and close it again by following the instructions.

When exiting the airplane, the door could be opened from the inside by depressing the lock button, and rotating the handle clockwise.

The "BEFORE TAKEOFF" checklist contained in the POH included the item, "Doors and Windows – SECURE."

According to the POH, if the cabin door was not properly latched, it could unlatch in flight. This could occur during or just after takeoff. The door would trail open approximately 3 inches and result in a reduced rate of climb, but the flight characteristics of the airplane would otherwise not be affected. The procedure for an unlatched door in flight was to "Return to the field in a normal manner."

Beechcraft Mandatory Service Bulletin

In 1993, Beechcraft had received reports of the third latch pin (lower aft latch pin) on the cabin door retracting in flight due to misrigging and/or vibration. When the latch pin retracted, it would force the entire door latching mechanism to reverse, allowing the cabin door to open.

As a result, in September 1993, Beechcraft released Mandatory Service Bulletin No. 2457, which required that Kit 36-4007 be installed to modify the cabin door by adding a third latch pin overcenter mechanism, modify the bellcrank assembly for the third latch pin, and replace the original third latch pin guide assembly with a redesigned one to reduce the possibility of a cabin door opening in flight.

Comparison of the accident airplane's internal door locking mechanism to an exemplar internal door locking mechanism revealed that the door had not been modified in accordance with the mandatory service bulletin. Review of the airplane maintenance records also did not indicate that the mandatory service bulletin had been accomplished.

The pilot's spouse advised that they had the "door light" come on a few times before the accident, and that the door was hard to latch.

Review of the POH indicated that the annunciator panel in the airplane contained three annunciators placarded "LOW BUS VOLTS", "START", and "AFT DOOR." No indication of an annunciator being mounted in the panel for the forward cabin door was discovered.

Air Speed Information

Review of the GPS data showed that the airplane's groundspeed dropped to 69 knots prior to its rapid descent. Calculations using the wind vector solutions function of an E6-B flight computer indicated that the true airspeed of the airplane at that point, would have been about 79 knots, which was below the published stall speed in the Beechcraft Bonanza Pilot's Operating Handbook (POH) for banked turns in e

NTSB Probable Cause

The pilot's failure to maintain control of the airplane after a cabin door came open in flight, which resulted in the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall. Contributing to the accident was the pilot's misuse of amphetamine.