NTSB Factual Report

HISTORY OF FLIGHT

On May 18, 2015, at 1238 eastern daylight time, a Beech 95-B55 (T42A), N5816S, was destroyed during a collision with terrain near Saltville, Virginia. The commercial pilot and passenger were fatally injured. The airplane departed Spruce Creek Airport (7FL6), Daytona Beach, Florida, about 0920, and was destined for Mansfield Lahm Regional Airport (MFD), Mansfield, Ohio. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the personal flight conducted under the provisions of 14 Code of Federal Regulations Part 91.

Information from the Federal Aviation Administration (FAA) revealed that at 1214:05, the airplane was in cruise flight at an altitude about 9,000 feet mean sea level (msl) when the pilot contacted Tri-Cities approach control (TRI), and the controller issued the altimeter setting. At 1220:02, the controller asked the pilot his on-course heading, and the pilot responded "356 degrees." The controller advised the pilot of "areas of weather, ah 12 o'clock and ah about four zero miles, just scattered areas, type and intensity unknown." The pilot stated he would "like to deviate east if we could," and the controller approved deviations left and right as necessary, and to maintain 9,000 feet. At 1232:16, the TRI controller switched the pilot to the Indianapolis Air Route Traffic Control Center (ZID) and the pilot acknowledged. The pilot never contacted ZID, and there were no further communications between the accident airplane and air traffic control.

Radar data depicted an easterly deviation off course, along with a gradual descent, before the radar target disappeared.

A search was initiated and the airplane wreckage was discovered in heavily wooded, mountainous terrain on May 19, 2015.

PERSONNEL INFORMATION

The pilot held a commercial pilot certificate with a rating for airplane single-engine land, multiengine land, and instrument airplane. His most recent FAA second-class medical certificate was issued July 2, 2013. A review of the pilot's logbook revealed he had accumulated 2,852.3 total hours of flight experience, 167 hours of which were in the accident airplane make and model.

AIRCRAFT INFORMATION

According to FAA records, the airplane was manufactured in 1965. While the airplane maintenance logs were not recovered, detailed records and invoices from the airplane's maintainer revealed its most recent annual inspection was completed August 15, 2014, at 4,094.9 total airframe hours.

The airplane was equipped with an EWR50 Weather Receiver, which was capable of displaying XM Weather information.

METEOROLOGICAL INFORMATION

At 1235, the weather recorded at Tazewell County Airport, 8 nautical miles north of the accident site, included scattered layers at 2,900 feet, 3,600 feet, and a broken ceiling at 8,000 feet with 10 miles visibility. The wind was from 210 degrees at 5 knots. The temperature was 24 degrees C, and the dew point was 18 degrees C. The altimeter setting was 30.26 inches of mercury.

The accident pilot received two official weather briefings from Direct User Access Terminal Service (DUATS) and one briefing text via ForeFlight Mobile prior to the flight.

The weather briefing information contained the closest departure and destination meteorological aerodrome report (METAR) observations, the terminal aerodrome forecast (TAF) for the destination, which mentioned thunderstorm activity possible by 1400, airmen's meteorological information (AIRMETs) valid for IFR and mountain obscuration, Center Weather Advisories valid for low IFR conditions, TAF and METAR information for surface stations along the route of flight, and wind aloft information.

Review of the accident pilot's DUATS sessions revealed that he reviewed the Area Forecast information for North Carolina and points southward, but did not review the Area Forecast information for points north of the North Carolina border. The 0445 Area Forecast for points north of the North Carolina border forecasted scattered to a broken ceiling around 5,000 feet msl, with scattered rain shower and thunderstorm activity as early as 1500 in southwestern Virginia, as early as 1100 in northern West Virginia, as early as 1400 in southern West Virginia, and as early as 1100 in southern Ohio. There is no record of the accident pilot receiving or retrieving any other weather information before the accident flight.

At 1248, 10 minutes after the accident, a significant meteorological information (SIGMET) for thunderstorms was issued for the area surrounding the accident site.

An NTSB Senior Meteorologist completed a Weather Study, which discussed the forecast weather along the route of flight, the actual weather encountered, and the limitations of FIS-B NEXRAD and XM Weather composite radar data. The Study also depicted the weather images available around and before the accident time.

The XM Weather radar images from 1220 through 1235 displayed light echoes to the west and north of the accident site with only very light echoes approaching the southwest corner of the accident site region by 1235, with the majority of the moderate to heavy rain showers and thunderstorms north and west of the accident flight track.

The accident airplane's flight track obtained from air traffic control was also plotted on a Google Earth image for a time comparison with WSR-88D base reflectivity images taken from elevation scans initiated at 1240 and 1245. The images depicted the accident site within greater than 5 dBZ values at 1240, with that area of greater than 5 dBZ expanding in coverage and height by 1245.

According to the Study, it was likely that the accident airplane flew into a developing rain shower and updraft around the accident time. In addition, given that the rain shower development near the accident site occurred at the accident time it would have been very difficult for either XM Weather or FIS-B regional NEXRAD data to pick up the newest rain shower development, especially given the FIS-B regional NEXRAD and XM Weather were using composite weather radar data.

WRECKAGE AND IMPACT INFORMATION

The wreckage was examined at the accident site, and all major components were accounted for at the scene. The initial impact points were in a tree and a deep ground scar collocated near the peak of Flat Top Mountain. The airplane fragmented outside the crater, and was contained in an arc that reached about 50 feet beyond the crater and widened to about 60 feet at its widest point.

Control continuity could not be established due to extensive impact damage, however; parts associated with the wings, flaps, and ailerons were identified. Sheet metal and cabling associated with the empennage, horizontal and vertical stabilizers, as well as the elevators were identified.

The propeller systems were separated from their respective engines, and all propeller blades exhibited similar twisting, bending, leading edge gouging, and chordwise scratching. One tree trunk displayed deep, angular cuts with paint transfers consistent with the paint on the propeller blades.

The engines were each severely damaged by impact. Engine cylinders were separated from each engine and scattered around the crash site. The engines to which the cylinders had been installed could not be determined.

The magnetos were separated from each engine, and two magnetos were not located. The engines to which the remaining two magnetos were mounted on could not be determined. Later, two magnetos were discovered by recovery personnel. They were identified and matched to the right engine by serial number. None of the four magnetos were functionally tested due to impact damage.

Examination of the engines and engine accessories revealed no preimpact mechanical anomalies that would have precluded normal operation.

Some personal electronic devices were recovered for examination at the NTSB Recorders Laboratory in Washington, DC, however; the severity of the damage to each precluded any data recovery.

MEDICAL AND PATHOLOGICAL INFORMATION

The Office of the Chief Medical Examiner, Roanoke, Virginia, performed a post mortem examination on the pilot.

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma performed toxicological testing on the pilot.

ADDITIONAL INFORMATION

NTSB Safety Alert SA-011, Thunderstorm Encounters, included:

"Severe weather avoidance is primarily [the pilot's] responsibility."

"Approach control radar systems provide near-real-time weather depiction. En route centers receive weather radar information from National Weather Service NEXRAD sites that refresh the color precipitation data on ATC displays every 4 to 5 minutes. Be aware that en route weather displays may be a few minutes behind the storm and allow extra distance from reported intense precipitation, especially in front of fast-moving convective activity. Also be aware that cockpit NEXRAD data can be 15 to 20 minutes older than indicated on the cockpit display."

"ATC radar systems depict only precipitation. Controllers cannot use radar to warn of turbulence, icing, freezing rain, or other hazards to flight. However, the presence of substantial precipitation implies the existence of thunderstorm hazards such as severe turbulence and hail."

NTSB Safety Alert SA-017, In-Cockpit NEXRAD Mosaic Imagery – Actual Age of NEXRAD Data Can Differ Significantly From Age Indicated on Display, included:

"Weather radar "mosaic" imagery created from Next Generation Radar (NEXRAD) data is available to pilots in the cockpit via the flight information service-broadcast (FIS-B) and private satellite weather service providers."

"The age indicator associated with the mosaic image on the cockpit display does not show the age of the actual weather conditions as detected by the NEXRAD network. Instead, the age indicator displays the age of the mosaic image created by the service provider. Weather conditions depicted on the mosaic image will ALWAYS be older than the age indicated on the display."

"Although such situations are not believed to be typical, in extreme latency and mosaic-creation scenarios, the actual age of the oldest NEXRAD data in the mosaic can EXCEED the age indication in the cockpit by 15 to 20 minutes."

NTSB Probable Cause

The pilot’s flight into developing rain showers and updrafts, which resulted in a loss of airplane control and collision with terrain. Contributing to the accident were the pilot’s continued flight into forecast adverse weather conditions, and his reliance on weather technologies with known limitations and processing delays.