NTSB Factual Report

HISTORY OF FLIGHT

On August 20, 2002, about 1103 eastern daylight time, a Beech BE-55, N132WM, registered to a private owner operating as a 14 CFR Part 91 personal flight, collided with water about 2 miles east of Campbell County Airport, Jacksboro, Tennessee, about 3 minutes after the pilot indicated that he had the airport in sight and cancelled an instrument flight rules flight plan with Atlanta Center. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The airplane was destroyed. The commercial pilot was fatally injured. The flight originated from Warren County Memorial Airport, McMinnville, Tennessee, at 1029.

A witness stated he was sitting on his back porch about 100 yards above and overlooking Lake Norris when he heard a twin-engine airplane approaching his location. He heard a sound as if the airplane lost one engine. He looked up and observed the airplane descending in a 75-degree nose down attitude. He went inside his home, called 911 and informed them that an airplane had crashed in the vicinity of Indian River boat dock. Two other witnesses stated they were standing in their back yard, located about 400 yards north northeast of Lake Norris. The airplane was traveling from the northwest to the southeast. The airplane made a left turn estimated at a 45-degree bank, the nose of the airplane was observed to pitch down, and the airplane descended out of view. One engine sounded like it was missing, the engine quit, restarted for a second, followed by a metal-to-metal sound. Then there was silence, followed by an impact.

According to Nashville Automated Flight Service Station the pilot called at 1010, requested a weather briefing and filed an instrument flight rules flight plan to Jacksboro. The Atlanta Center Watch Supervisor stated review of transcripts revealed the pilot contacted Memphis Center at 1035 and cancelled the instrument clearance with Atlanta Center at 1100. The pilot stated he had the airport in sight and wanted to know if they had any traffic. The pilot was informed there was no traffic and to squawk 1200, and frequency change was approved.

Review of radar data obtained from Atlanta Center and Knoxville Terminal Radar Approach Control revealed the airplane over flew the airport at 4,900 feet while descending heading north east at 11:00:53. The airplane was observed at 3,800 feet making a left turn at 11:02:06. At 11:02:48, the airplane was observed in a left turn at 2,700 feet and passed by the approach end of runway 23 at Jacksboro. The airplane was last observed on radar at 11:03:20, at 2,200 feet before it collided with the lake.

PERSONNEL INFORMATION

Review of information on file with the FAA Airman's Certification Division, Oklahoma City, Oklahoma, revealed the pilot was issued a commercial pilot certificate on August 26, 1977, with ratings for airplane single engine land, multiengine land, and instrument airplane. The pilot was issued a flight instructor certificate on April 28, 2000, with ratings for airplane single and multiengine, instrument airplane. The pilot's last recorded biennial flight review was conducted on July 10, 2002. The pilot held a second-class medical certificate issued on December 4, 2001 with the medical restriction "holder shall possess glasses for near and intermediate vision." The pilot indicated on his application for the second-class medical certificate that he had accumulated 20,000 hours total flight time with 185 hours flown in the last six months. Review of the pilot's logbook revealed he had a total of 3,018.1 hours, and 296 hours in the Beech BE-55.

AIRCRAFT INFORMATION

Review of aircraft maintenance records revealed the last recorded annual inspection was completed on February 18, 2002, and the airplane had accumulated 80.1 hours since the annual inspection. The right main landing gear up lock cable was replaced on August 19, 2002, at Hobbs time 198.7, and the total airplane time was 5,239.0 hours. The right engine was overhauled February 8, 2000. The right propeller was overhauled on December 14, 1999. The right propeller assembly was not recovered. The airframe Hobbs indicator read 0200.2 hours at the crash site. The altimeters, transponder, altitude reporting and static system test were conducted on May 14, 2001. Review of refueling records on file at Oconee County Airport, Clemson, South Carolina revealed the pilot's airplane was topped off with 49.3 gallons of aviation 100 low lead fuel on August 16, 2002, and the airplane did not fly again until the day of the accident.

METEOROLOGICAL INFORMATION

The nearest weather reporting facility at the time of the accident was Oak Ridge, Tennessee. The 1053 surface weather observation was: wind calm, visibility 9 miles, a few clouds at 500 feet, temperature 77 degrees Fahrenheit, dew point temperature 73 degrees Fahrenheit. The Geostationary Operations Environmental Satellite Number 8 visible image at 1045 depicted an area of low stratiform clouds and fog surrounding the Jacksboro area with the airport relatively clear of the clouds and fog. The area approximately 1 mile east over the accident site however, was obscured by the low stratiform clouds and or fog.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located in 50 feet of water in Lake Norris, about two miles east of Campbell County Airport, Jacksboro, Tennessee.

Examination of the crash site revealed the nose section was separated from the fuselage and was not recovered. The firewall and attached instrument panel was separated from the fuselage. The fuselage from the firewall aft to the rear carry through structure sustained accordion compression damage. The left cabin wall was separated from the fuselage extending aft to the rear carry through structure. The right cabin sidewall and main cabin door were missing and not recovered. The fuselage floor separated from the rear carry through structure. The left and right fuselage extending aft from the rear baggage compartment to the tail cone was intact. The empennage remained attached to the rear fuselage.

The left wing was pushed aft. The front spar separated six inches outboard from the wing attachment fitting, and the rear spar separated from the rear carry through structure. The leading edge of the left wing sustained accordion crushing extending from the wing root outboard to the wing tip. The rear wing panel inboard of the left engine nacelle sustained diagonal crushing. The flaps and ailerons remained attached to the left wing. The flaps and landing gear were extended to the full down position. The left main fuel tank and the left auxiliary fuel tanks were ruptured. The left engine assembly separated from the engine mount.

Examination of the left engine revealed the propeller and crankshaft propeller flange were separated from the crankshaft. The engine assembly exhibited impact damage. The oil sump was crushed upward with a small inward puncture. The fuel manifold valve was intact and trace fuel was present in the bottom half of the valve. The fuel injector lines were intact, unobstructed, and a trace of fuel was present in the No. 1 injector line. All fuel nozzles were open and unobstructed. The engine was rotated by hand and valve and drive train continuity was confirmed to all cylinders except cylinder No. 5. A thumb compression check was performed and compression and suction was confirmed on all cylinders except for cylinder No. 5. The intake valves and springs sustained impact damage. The left and right magnetos were intact and contained water. When turned by a drill, both magnetos produced sparks from all ignition towers. The engine was totally disassembled and no abnormalities were observed.

Examination of the left propeller revealed the left propeller flange and attaching bolts were intact but the engine shaft was fractured about three inches from the flange. The No. 1 blade had rotated in its clamp approximately 90-degrees towards low pitch. The No. 2 blade had separated from its clamp. The No. 3 blade had rotated in its clamp about 10-degrees towards high pitch. It was noted the outer clamp bolt washers were deformed. During disassembly, it was noted that the outer clamp bolts retained greater than or equal to thirty five foot pounds of torque. The pitch change rod had an impact mark caused by contact with the front spring retainer. The pitch change rod was extended 2-6/32 inches from the feather position which equates to about 15-degrees blade angle.

The right wing was displaced forward and remained attached to the carry through structure. The leading edge of the right wing sustained accordion crushing extending outboard from the wing root to the wing tip. The leading edge of the wing was pushed aft and upward to the rear spar. The wing panel displayed diagonal buckling from the leading edge outboard side of the right engine nacelle to the rear spar at the wing tip. The flap and aileron remained attached to the right wing. The flaps and landing gear were extended to the full down position. The right main fuel tank and right auxiliary fuel tank were ruptured. The right engine assembly separated from the engine mount. The right crankshaft separated behind the crankshaft propeller mounting flange and the right propeller assembly was not recovered.

Examination of the right engine revealed the propeller and crankshaft propeller flange were separated from the crankshaft. The engine assembly exhibited impact damage. The right crankcase half was cracked at the bottom of the No. 5 cylinder from the backbone to the No.5 cylinder deck top stud and down to the bottom right side of the No. 5 cylinder deck. The oil sump was crushed upward with a several inward punctures. The fuel manifold valve was intact and trace fuel was present. The fuel injector lines were intact, with impact damage to No. 2, 4, and 6 injector lines. All fuel nozzles were open and unobstructed except for No. 3 which contained foreign matter. The left and right magnetos were intact. When turned by a drill, both magnetos produced sparks from all ignition towers. The engine was totally disassembled and no abnormalities were observed.

Examination of the flight controls revealed all components necessary for flight were present at the crash site. Control continuity was established to the primary and secondary flight controls. The control column assembly, and elevator pushrods were intact. The aileron control cables and chain were intact and the chain was engaged with the sprocket at the base of the control column. The control arms on each aileron bellcrank located in the left and right wing were separated from the aileron bellcrank.

MEDICAL AND PATHOLOGICAL INFORMATION

The University of Tennessee Medical Center, Forensic Pathologist, Medical Examiners Office, Knoxville, Tennessee, conducted a postmortem examination of the pilot on August 23, 2002. The cause of death was multiple blunt force injuries. In addition, the autopsy narrative notes that...."Of interest at autopsy, was the presence of severe atherosclerotic heart disease including multiple microscopic foci of myocardial fibrosis indicative of prior ischemic events within the myocardium....The "Accessory Diagnoses" include the following:

1. Atherosclerotic cardiovascular disease

a. Coronary atherosclerosis, severe

I. Occlusion of right coronary artery by calcified atherosclerotic plaque 3.0 cm from origin

ii. Left anterior descending coronary artery with greater than 90 percent stenosis by calcified atherosclerotic plaque at origin

iii. Left circumflex coronary artery with 50 percent stenosis by calcified atherosclerotic plaque 2.0 cm from origin

iv. Myocardial fibrosis, multifocal, microscopic

b. Aortic atherosclerosis, severe

2. Hepatic cirrhosis with steatosis

a. Splenomegaly

3. Hypertensive cardiovascular disease

a. Arteriolonephrosclerosis

b. Hypertrophic changes of myocardial fibers, microscopic"

Postmortem toxicology of specimens from the pilot were performed by the Forensic Toxicology Research Section, Federal Aviation Administration, Oklahoma City, Oklahoma. The results were negative for carbon monoxide, cyanide, and ethanol. Acetaminophen, 2.961 (ug/ml, ug/g) often referred to by the brand name Tylenol was detected in the blood.

Review of the pilots medical records maintained by the FAA Aerospace Medical Certification Division revealed no medications, medical conditions, abnormal physical findings, or visits to medical professionals other than for the FAA medical examinations.

ADDITIONAL INFORMATION

The wreckage was released to Atlanta Air Salvage, Griffin, Georgia on August 23, 2002. The pilot's logbook was released to the deceased pilot's wife on August 27, 2002.

NTSB Probable Cause

Pilot incapacitation due to a heart attack resulting in a loss of control and the subsequent in-flight collision with a lake.