NTSB Factual Report

HISTORY OF FLIGHT

On August 26, 2012, about 1118 eastern daylight time, a Beech B24R Sierra, N9200S, was substantially damaged when it collided with trees and terrain during a forced landing after a reported loss of engine power near Dayton, Virginia. The certificated private pilot was fatally injured. Instrument meteorological conditions (IMC) prevailed, and no flight plan was filed for the personal flight that originated from Wilmington International Airport (ILM), Wilmington, North Carolina, at 0903. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

At 0831 the morning of the accident, the pilot phoned the Raleigh Automated Flight Service Station (AFSS) and obtained a preflight weather briefing. During the briefing, he was advised multiple times that visual flight rules (VFR) flight was not recommended due to existing and forecast IMC along his intended route of flight. The pilot departed at 0903 without filing a flight plan.

According to the Federal Aviation Administration (FAA), at 1109, the pilot contacted air traffic control, and advised that he was climbing the airplane from 9,000 to 10,500 feet. At 1111, the pilot declared an emergency, advised he had "lost" the engine, and stated that he was "VFR on top."

The controller initially provided vectors to Bridgewater Airpark (VBW), Bridgewater, Virginia, and then to Frank Field (VA52), Harrisonburg, Virginia. He attempted to orient the pilot to the airplane's position relative to the two airports, so that he could acquire the airports visually, but at 1112, the pilot advised he was "still in the soup and can't see much of anything at this point." At 1117, the pilot stated that the airplane was unable to clear a ridgeline in its flight path and shortly thereafter, radar and voice communication with the airplane was lost. At that time, the airplane was located on a bearing 301 degrees and 8 nautical miles from VBW.

PERSONNEL INFORMATION

The pilot/owner held a private pilot certificate with a rating for airplane single engine land. His most recent FAA third-class medical certificate was issued on November 2, 2010. He reported 600 total hours of flight experience on that date. The pilot's logbook was recovered and reviewed at the accident site. Examination revealed the pilot had logged approximately 235 total hours of flight experience, of which 206 hours were in the accident airplane. The pilot did not possess an instrument rating.

AIRCRAFT INFORMATION

According to FAA records, the airplane was manufactured in 1975, and had accrued 3,206.9 total aircraft hours. The most recent annual inspection was completed November 19, 2011, at 3,192.5 aircraft hours.

METEOROLOGICAL INFORMATION

At 1115, the weather conditions reported at Shenandoah Valley Regional Airport (SHD), located 15 miles southeast of the accident site at 1,201 feet elevation, included scattered clouds at 1,800 feet, a broken ceiling at 3,300 feet, and an overcast ceiling at 4,000 feet. There was 10 miles visibility; the temperature was 22 degrees C, dew point 18 degrees C, and an altimeter setting of 30.24 inches of mercury. The wind was from 100 degrees at 4 knots.

WRECKAGE INFORMATION

The wreckage was examined at the accident site on August 26, 2012, at 1,869 feet elevation, and all major components were accounted for at the scene. There was no odor of fuel or evidence of fuel spillage. The wreckage path was oriented 245 degrees magnetic, and was about 60 feet in length. The initial impact point was in a treetop about 40 feet above the ground. The second tree strike was approximately 20 feet farther along the wreckage path, about 20 feet above the ground. The 4-inch trunk displayed a sharp, angular cut with paint transfer consistent with the paint on the propeller blades. The initial ground scar was about 55 feet along the wreckage path, and immediately in front of the airplane, which came to rest, upright, and facing opposite the direction of travel.

The engine, firewall, instrument panel, and cockpit areas showed significant impact damage and airframe deformation. The leading edges of both wings displayed aft crushing, and about 4 feet of the outboard section of each wing was separated. Control cable continuity was established from the cockpit to the rudder and elevator. Cable continuity was established through cable breaks to the ailerons. All cable breaks displayed failure due to overload.

The fuel tanks were intact, and about one pint of fuel was drained from the left tank while 10 gallons was drained from the right. The fuel selector was in the right tank position. Continuity of the entire fuel system was confirmed. The gascolator was removed and disassembled. It contained no fuel, was completely dry, and was absent of debris. The fuel boost pump, as well as the boost pump switch, was destroyed by impact.

The engine was recovered from the scene and examined at SHD on August 28, 2012. The engine was partially disassembled to facilitate examination due to impact damage to the inlet air box, and the intake and exhaust tubes. The engine was rotated by hand and continuity was established through the powertrain and valvetrain to the accessory section. Compression was confirmed on all cylinders using the thumb method. Borescope examination of each cylinder revealed no anomalies. The magnetos were removed, rotated by hand, and produced spark at all terminal leads. The engine-driven fuel pump was removed, actuated by hand, and pumped fluid.

The fuel flow divider was removed and disassembled. The flow divider contained a few drops of fuel and was absent of debris. The fuel injector lines and nozzles for each cylinder were clear and absent of debris.

The fuel injector servo was impact damaged, and the mixture and throttle control settings could not be determined.

MEDICAL AND PATHOLOGICAL INFORMATION

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing for the pilot. The following Tested-for-Drugs were detected:

Fluoxetine and Norfluoxetine were detected in blood and urine.

Fluoxetine (Prozac) belonged to a class of drugs called selective serotonin reuptake inhibitors (SSRIs). It was used in adults for the treatment of major depressive disorder, panic disorder, obsessive-compulsive disorder, bulimia (eating disorder), treatment-resistant depression, and depression associated with bipolar disorder. In children and adolescents, fluoxetine was used to treat major depression and obsessive-compulsive disorder.

Norfluoxetine was a metabolite of Fluoxetine.

Examination of the pilot's personal and FAA medical records revealed that Norfluoxetine was prescribed to the pilot by a physician, but that he did not disclose its use on his most recent application for an FAA medical certificate.

The Office of the Chief Medical Examiner for the Commonwealth of Virginia, performed an autopsy on the pilot in Roanoke, Virginia. The cause of death was the result of blunt force trauma to the head and chest.

ADDITIONAL INFORMATION

At the time of the accident, there was an active AIRMET SIERRA for mountain obscuration for the area surrounding the accident site. Based on infrared satellite imagery from GOES-13 at 1115, cloud top temperatures in the immediate vicinity of the accident location ranged between 6 degrees C to 9 degrees C. Interpolation of rawinsonde data from a 0800 launch at Sterling, Virginia, revealed these temperatures corresponded to cloud-top heights of approximately 9,000 to 7,200 feet, respectively.

The airplane was equipped with one 29.9 gallon fuel tank in each wing. Of the 59.8 gallons on board, 52.2 gallons were usable. According to the manufacturer's pilot operating handbook, Section V – Performance, Cruise Power Settings, at 75 percent maximum continuous power (or full throttle), the nominal fuel flow was 10.2 gallons per hour.

NTSB Probable Cause

The pilot's improper fuel management, which resulted in fuel starvation and a total loss of engine power. Contributing to the accident was the noninstrument-rated pilot's decision to attempt a visual flight rules flight in instrument meteorological conditions over mountainous terrain.