NTSB Factual Report

HISTORY OF FLIGHT

On August 12, 2016, at 1222 eastern daylight time, a Beech 95-B55, N128VB, collided with trees and terrain during an aborted landing at Shannon Airport (EZF), Fredericksburg, Virginia. The private pilot and five passengers, one of whom was a commercial pilot, were fatally injured. The airplane was registered to Ross and Company PLL and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed near the accident site at the time of the accident, and no flight plan was filed for the cross-country flight, which originated from Shelbyville Municipal Airport (GEZ), Shelbyville, Indiana, about 1015.

The pilot departed Bowman Field Airport (LOU), Louisville, Kentucky, earlier in the day and flew to GEZ to pick up his commercial pilot-rated friend and four additional passengers. A lineman at GEZ stated that after the airplane landed, the pilot parked the airplane next to the fuel pump and requested that the main inboard fuel tanks be "topped off." The pilot was the only person onboard the airplane at the time. The lineman stated that after he topped off the left tank, the pilot-rated passenger requested that he "leave the right tank down an inch or two." The lineman obliged; he added a total of 40.3 gallons of fuel to the airplane. The lineman also stated that he overheard a conversation between the pilot and the pilot-rated passenger, during which the owner stated, "we have 15 gallons in each of the aux[iliary] tanks." Based on the information provided by the lineman, the total fuel on board after the refueling was estimated to be about 100 gallons; The airplane had two auxiliary fuel tanks each holding about 15 gallons and two 37-gallon main tanks that were nearly topped off, with about 4 gallons subtracted from right tank.

A pilot-rated witness reported that once fueling was completed, six people boarded the airplane, with the pilot occupying the left front seat and the pilot-rated passenger occupying the right front seat. The other four passengers occupied the second and third rows of seats. The witness stated that he did not see any luggage or cargo being loaded on board.

The witness also reported that the pilot had difficulty starting the airplane's engines and that the pilot attempted to start the engines for 10 to 15 minutes before the pilot-rated passenger yelled out the door, "Any ideas?" The witness assisted them with troubleshooting procedures that included turning on the boost pumps; the engines were successfully started, and the airplane departed. The witness stated that he noticed that the airplane appeared to "porpoise" down the runway during the takeoff roll. The airplane departed about 1005.

The pilot established contact with air traffic control (ATC) at 1013 and requested radar flight following services to EZF. The flight continued to EZF at an altitude of 7,500 ft mean sea level (msl). Between 1121 and 1136, ATC could not contact the pilot, but communications were reestablished as the flight crossed into the airspace of the North Central West Virginia Airport (CKB), Clarksburg, West Virginia. The flight was subsequently transferred to Washington ARTCC and Potomac Consolidated TRACON before finally being advised to contact approach controllers at Quantico Marine Corps Airfield,(NYG), Quantico, Virginia. Quantico approach advised the pilot that EZF was ahead at 12 o'clock and 4 miles and subsequently issued the pilot a radio frequency change to the common traffic advisory frequency there; the pilot advised he had the airport in sight, which was the last recorded communication with the flight.

An Appareo Stratus 2S ADS-B receiver was recovered from the wreckage and sent to the NTSB Recorders Laboratory in Washington, DC, for examination and download. The recovered data provided position, barometric altitude, and groundspeed, as well as three-axis attitude and acceleration. The timestamps associated with the data were provided in elapsed seconds since the beginning of the recording and are presented in this report as seconds elapsed since the airplane reached a point about 20 nautical miles from EZF.

The airplane approached EZF from the northwest and entered a left crosswind for runway 24 about 807 seconds into the recorded data. The airplane then entered a downwind leg at 827 seconds and began the final approach at 1,027 seconds. At the start of the final approach, about 3/4 nautical mile from the runway, the airplane had descended to an altitude of 614 feet msl and a groundspeed of 102 knots. As the airplane reached about 1/4 nautical mile from the runway, the airplane had reached 232 feet msl and a groundspeed of 95 knots. As the airplane crossed the runway threshold, it had descended to 122 feet msl (about 40 feet above the runway), with a groundspeed of 87 knots. About 500 feet down the runway, the airplane's groundspeed was 77 knots and the altitude was 103 feet msl (about 20 feet above the runway). At 1,097 seconds, the airplane crossed the midpoint of the 2,999-foot-long runway at a groundspeed of 64 knots. About 3 seconds later, as the airplane's speed decreased to 60 knots groundspeed, it pitched up then began a climbing left turn, while slowing to 54 knots groundspeed and a positive pitch of about 15.4°. About 30 seconds after beginning the climb, while on a heading of 198°, the pitch up and left roll increased rapidly immediately before impact.

Several witnesses observed the airplane on final approach to runway 24 at EZF. One witness stated that the airplane appeared "high" as it approached the runway and that it was traveling fast. Two other witnesses stated that airplane "landed long," bounced several times, and initiated a go-around. The witnesses reported that both engines seemed to be producing power.

The airport was equipped with a security camera that captured the departure half of runway 24. The security camera recorded the airplane as it entered the field of view when it was about 1,400 ft from the approach end of runway 24 and continued to record the airplane until it impacted terrain south of the airport. Review and computational study of the recorded video revealed that when the airplane came into view, it was slightly above the runway and moving at a speed of about 70 knots with the landing gear and flaps extended. The airplane then began to climb, and its speed started decreasing. When the airplane was at an altitude of about 50 ft above ground level, the speed decreased to about 58 knots before it abruptly pitched up and rolled to the left, then descended and impacted the ground.

PILOT INFORMATION

According to Federal Aviation Administration (FAA) records, the pilot, age 73, held a private pilot certificate with ratings for airplane single-engine and multi-engine land. The pilot did not possess a current medical certificate at the time of the accident. (For more information about the pilot's medical status, see the Medical and Pathological Information section of this report.)

Review of the pilot's logbook revealed that he had accumulated 233.2 total hours of flight experience since April 30, 2001. His first recorded flight in the accident airplane was conducted on March 16, 2008, and he had logged a total of 189.1 hours in the airplane. According to the logbook, the pilot's flying was inconsistent with months of time between flights. In the previous 12 months and 90 days, he had logged 9.4 hours and 2.6 hours, respectively, all in the accident airplane. His most recent flight in the airplane was in June 2016.

The pilot-rated passenger, age 64, held a commercial pilot certificate with ratings for airplane multi-engine land, single-engine land, single-engine sea, and instrument airplane. His most recent FAA second-class medical certificate was issued on May 11, 2016, with the limitation that he must have available glasses for near vision.

A review of the pilot-rated passenger's logbook showed that he had accumulated 2,273 total hours of flight experience, of which 1,149.4 hours were in multi-engine airplanes. He had logged 5.9 hours in the accident airplane make and model (all in the accident airplane), and his last logged multi-engine flight was conducted in the accident airplane on October 22, 2015. Further review of his logbook showed that he had accumulated a total of 66.1 hours flight experience in multi-engine airplanes in the previous 10 years.

AIRCRAFT INFORMATION

The six-seat, twin-engine, low-wing, retractable-gear airplane was manufactured in 1969. It was equipped with 260-horsepower Continental IO-470-L engines and three-blade, controllable-pitch, Hartzell propellers.

According to the airplane's maintenance records, the most recent annual inspection was completed on May 15, 2016, at an airframe total time of 4,224.4 hours.

The airplane's maintenance records indicated that, on February 1, 2014, at 4,689.0 hours total time and 518 hours since major overhaul, the left engine was "disassembled, cleaned, inspected, repaired, and assembled." Also, at 2,301.4 hours total time and 620.8 hours since major overhaul, the right engine was "disassembled, repaired, and reassembled." On May 15, 2016, 61.9 hours after the February 1, 2014 engine work, both engines underwent their most-recent 100-hour inspection as part of the aircraft's annual inspection.

Weight and balance calculations were performed based on the airplane's empty weight and balance as determined on October 11, 1999. The weights of the two pilots were acquired from medical records, while the weights of the four passengers were estimated based on medical autopsy results. The estimated weight at takeoff was 4,979 pounds, which was below the airplane's maximum gross weight of 5,100 pounds, while the estimated weight at landing was 4,679 pounds. The estimated centers of gravity for takeoff and landing were 84.5 inches and 84.6 inches, respectively, which were within the limits of 81.0 to 86.0 inches.

The pilots operating handbook (POH) for the airplane in section IV, Normal Procedures lists the following airspeeds for safe operations; two-engine best angle of climb speed is 84 knots, the best rate of climb speed is 107 knots, the balked landing climb speed is 90 knots, and the stall speed with landing gear extended and flaps down is 73 knots. The stall speed with the flaps in the retracted position is 79 knots. A calculation of the airplane's expected landing distance assuming an approach at the prescribed airspeed of 86 knots at 50 feet above the ground, the weather conditions that prevailed at the time of the accident, and the airplane's estimated landing weight, indicate that the runway required to safely land and stop was 1,280 feet, with about 1,850 feet needed to clear a 50-foot obstacle.

METEOROLOGICAL INFORMATION

At 1235, the reported weather at EZF was wind from 200° magnetic at 10 knots, wind direction variable from 190° to 250°, visibility 10 statute miles, sky clear, temperature 34°C, dew point 24°C, and altimeter setting of 29.96 inches of mercury.

AIRPORT INFORMATION

EZF was located about 2 miles south of Fredericksburg, Virginia. It was classified by the FAA as a public airport. The airport elevation was 85 ft msl. Runway 24 was oriented 235 degrees magnetic and was 2,999 feet long by 100 feet wide. It was an asphalt runway in good condition and was equipped with a visual approach slope indicator.

WRECKAGE AND IMPACT INFORMATION

The accident site was located about 700 ft south-southeast of the departure end of runway 24 on an embankment adjacent to a railway service road. All major components of the airplane were accounted for at the scene. Trees surrounding the accident site exhibited gouges, angular-cut branches, and paint transfers from the top of the tree canopy down toward ground level, and several pieces of angular-cut tree branches were discovered near each engine.

The airplane was found upright on the ground with the rear fuselage and empennage suspended from 5-ft-high bushes. The airplane's fuselage, including the nose, instrument panel, cockpit, and cabin, was consumed by a postimpact fire. Both wings were separated from their respective fuselage attach points. The left engine remained partially attached to the left wing and was found in an inverted position about 15 ft from the fuselage. The right engine was separated from the right wing, and the right propeller assembly was separated from the right engine. All right wing components were found within 20 ft of the fuselage.

The elevator and rudder flight control cables were attached to their respective rear fuselage bell cranks. The rear elevator bell crank upper arm was separated, and the separated arm was attached to the up-elevator flight control cable. The elevator and rudder flight control cables were traced forward toward to the cockpit. The right aileron bell crank and right aileron cable were not identified due to thermal and impact damage, and the left aileron cable and the aileron balance cable remained attached to the left aileron bell crank. The left aileron cable was not observed at the point where it entered the cabin area. The cockpit aileron cable and chain assembly and the aileron sprocket were not observed. The flight controls were consumed by fire, but the dual yoke system remained connected to the two independent control chains that went from the center control arm wheel to their respective left and right seat positions.

Visual examination of the left and right flaps indicated that the flaps were in the up/retracted position. The flap handle in the cockpit was destroyed. The left flap actuator had thermal and impact damage, and the flap setting could not be determined. The right flap actuator remained intact and indicated that the flap was in the up/retracted position.

The cockpit trim controls and indicators were destroyed. Visually, the tab trailing edges were in neutral positions. The two fuel selector valve assemblies were partially consumed by the postimpact fire; the fuel valve rotors were positioned to the left and right main wing tanks, respectively.

The landing gear actuator housing was consumed by the postimpact fire. The three landing gear assemblies remained attached to the airplane structure and were found in the retracted positions.

The magneto switches in the cockpit were exposed to impact and thermal damage. The left magneto switch appeared to be positioned on the left magneto, and the right magneto switch appeared to be positioned on both.

Left Engine

The left engine came to rest inverted on the side of the embankment. The engine sustained thermal damage to the aft and bottom sides. The engine contained clean oil, and the observed engine components appeared to be well lubricated. A continuity check resulted in crankshaft and camshaft continuity throughout the drive and valve trains with thumb compression observed on all six cylinders. The spark plugs remained secured to their respective cylinders. The top spark plugs were removed and examined. They all appeared to have minimal wear when compared to the Champion Check-A-Plug chart and did not display any evidence of carbon or lead fouling that would preclude normal operation. No pre-accident anomalies were noted with the engine.

The throttle body remained attached to the aft section of the engine, and the fuel metering unit remained attached to the throttle body. The induction air box remained attached to the throttle body. The throttle and mixture cables remained attached to their respective control levers. Removal of the induction air box revealed that the throttle valve was intact on the shaft, and burnt debris was noted on the throttle plate. The fuel lines to and from the metering unit remained attached to their respective fittings, but the fuel lines were thermally damaged.

The fuel manifold valve remained attached to the topside of the engine, and all fuel lines remained attached to their respective fittings. The fuel injector lines remained attached to their respective nozzles with no pre-accident anomalies noted.

The oil sump was intact, and the quick drain plug was not damaged. The accessory gears appeared to be lubricated and coated with oil. The oil pum

NTSB Probable Cause

The pilot(s) failure to maintain adequate airspeed during an attempted go-around, which resulted in an exceedance of the airplane's critical angle of attack and an aerodynamic stall.