NTSB Factual Report

HISTORY OF FLIGHT

On October 23, 1994, about 2045 Pacific daylight time, N333KS, a Beech BE-58, operated by the owner/pilot, impacted terrain during an uncontrolled descent and was destroyed at Shaw Island, Washington. The uncontrolled descent occurred immediately after takeoff from a private unlit airstrip at night. The private pilot and his passenger were fatally injured. There was no fire. Visual meteorological conditions prevailed and no flight plan had been filed. The personal flight was conducted under 14 CFR 91 and was destined for Bellingham, Washington.

According to acquaintances of the pilot who had been with him during the 72 hours prior to the accident, the pilot had routinely flown into the airstrip because he had a second home on Shaw Island. The acquaintances also indicated that the pilot sometimes took off from the airstrip at night. On Friday evening, October 21, one of the pilot's acquaintances was picked up in Seattle and flown by the pilot to Shaw Island in N333KS. The acquaintance stated that he saw a deer on the runway during the landing, and that deer were frequently seen on the airstrip in the evening. The acquaintance stated that other acquaintances of the pilot shot a deer on Friday and another on Saturday at the airstrip.

The following morning, October 22, 1994, one day prior to the accident, the pilot flew from Shaw Island to Anacortes, Washington, to duck hunt, then back to Shaw Island to pick up three acquaintances, then on to Bellingham. In Bellingham, two of the three acquaintances were dropped off. The remaining acquaintance and the pilot departed for Boeing Field in Seattle, Washington, where the airplane was fueled. The two occupants attended a wedding reception in Seattle during the afternoon. After the reception, the pilot "took a nap" for about two hours, and the couple then went to dinner.

The couple remained in Seattle overnight. According to the acquaintance, the pilot went to sleep about 2330 and awakened about 0830 on the following morning, the day of the accident. The acquaintance reported that the pilot was feeling "fine," and was not observed consuming any drugs. Later that afternoon, the pilot flew by himself from Seattle to Bellingham, where he invited two friends to fly back to Shaw Island to "have dinner and watch the sunset." One of the friends accepted, and the two departed Bellingham and landed at Shaw Island about 1730. The pilot appeared to be in "a great mood" in Bellingham, and no problems with the airplane were mentioned.

The acquaintance of the pilot who had flown with him to Seattle stated that she telephoned the pilot about 1830 on the evening of the accident. She stated that the pilot was "putting dinner on at home" and that he would be home in Bellingham about 2100. She also stated that the pilot did not mention any problems with himself or the airplane.

The owner of the airstrip, who resides about 150 yards from the north end of the airstrip, reported hearing the accident airplane's engines starting about 2045 hours. He then heard the airplane being taxied from the center of the airstrip to the north end of the runway and begin to takeoff with "partial throttle." About five seconds later, the engines sounded like they were at "full throttle." The owner of the airstrip also stated that the engines "sounded normal" just prior to ground impact.

The accident occurred during the hours of darkness at 48 degrees, 34.2 minutes North and 122 degrees, 58.2 minutes West.

PERSONNEL INFORMATION

The pilot, age 38, was a certificated private pilot with ratings for single and multi-engine land airplanes, and instrument airplane. According to FAA records, the pilot was issued an FAA Third Class Medical Certificate on October 1, 1993, with no limitations or waivers. The pilot's personal logbook was recovered at the accident site; entries in the logbook indicated that the pilot had logged a total of 818 hours of flight time prior to the accident flight, including 257 hours in type, 123 hours at night, and 178 hours of instrument flight time.

AIRCRAFT INFORMATION

The airplane, a 1973 Beech BE-58 "Baron," was owned and operated by the pilot since March 2, 1993. The airplane had received a supplemental type certificate (STC) for a Colemill Enterprises, Inc. "Foxstar" conversion. The conversion involved the installation of two Continental IO-550-C engines, two Hartzell propellers, a modified nose cowling, and winglets. Another STC allowed the installation of 107 vortex generators to the airplane's wings and vertical stabilizer. The published minimum controllable airspeed of the airplane was 74 knots (calibrated).

An examination of the airplane's engine and airframe logbooks did not reveal any unresolved discrepancies prior to departure on the day of the accident. The airplane had logged 3,532 hours at the time of the accident.

AERODROME INFORMATION

The departure airstrip is privately owned and has a 2100- foot grass runway oriented north-south. The runway grating (from north to south) slopes downward to a vertical depth of about 20 feet near midfield, and then rises again to level terrain prior to the southern (departure) threshold. The airstrip is not lighted or controlled, nor are there any lights in the immediate vicinity. The runway is surrounded by trees, and powerlines border the north perimeter of the airstrip. Permission to operate on the airstrip must be obtained by the owner, and permission was granted for the accident pilot.

WRECKAGE AND IMPACT INFORMATION

The airplane wreckage was examined at the accident site on October 24, 1994. An additional examination occurred on October 27, 1994, at Boeing Field, Seattle, after the wreckage had been moved.

The airplane came to rest adjacent to a line of undamaged trees about 100 feet east of the eastern edge of the runway, and 225 feet north of the southern threshold. The airplane's longitudinal axis and the wreckage distribution path were oriented along a magnetic heading of 327 degrees, nearly opposite it's direction of takeoff. No evidence of fire was found.

Both propellers were embedded into the ground and broken off at their flanges. The right and left propellers were extracted from craters that measured 19 inches and 12 inches in depth respectively. The remainder of the airplane had separated from the propeller hubs and was resting upright about 45 feet from the propellers. Both propellers exhibited symmetrical bending and torsional damage. Two blades on each four-blade propeller exhibited S-bending, chordwise scratching, and leading edge gouging. One blade exhibited a sheared tip.

Fuel was found in both wing tanks. Both cockpit fuel selectors were found in the ON position. The non-volatile memory from the airplane's digital fuel quantity indicator was extracted under the supervision of the Safety Board; the extraction revealed that 142 gallons of available fuel was being registered on the indicator at impact.

Both engines underwent a detailed visual inspection and partial teardown; no evidence of pre-impact mechanical deficiencies was found.

All primary and secondary flight control surfaces were accounted for at the accident site. The entire airframe was located within its own dimensions. No evidence was found to indicate a flight control deficiency. The leading edges of both wings exhibited evidence of "accordion" crush damage. The flaps were found in the retracted position, and the landing gear was found in the extended position.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by Dr. Laurence R. Peterson, M.D., of Skagit Pathology, Inc., Mount Vernon, Washington, 98273, on October 25, 1994. According to the report of autopsy, no evidence of pre-existing disease was found.

A toxicological analysis (attached) was performed on blood specimens taken from the pilot by the Washington State Toxicological Laboratory, Seattle, Washington. According to the report, 0.12 grams per 100 milliliters of ethanol was detected in the blood.

Another toxicological analysis was performed on specimens taken from the pilot by the FAA Civil Aeromedical Institute, Oklahoma City, Oklahoma. According to their report, dated April 27, 1995 (attached), "98.000 [milligrams per deciliter] ethanol detected in Blood" and "5.000 (milligrams per deciliter) 2-Propanol detected in Vitreous Fluid." The report also stated "The ethanol found in blood is most likely from postmortem ethanol production."

The FAA toxicological report also indicated that "0.272 (ug/ml, ug/g) Benzoylecgonine detected in Urine" and "Benzoylecgonine detected in Liver Fluid." Benzoylecgonine is a metabolite of the drug cocaine.

The FAA toxicological report further indicated that "0.050 ug/ml Chlorpheniramine detected in Liver Fluid" and that Chlorpheniramine was detected in blood and urine specimens. The report also indicated that Pseudoephedrine was detected in blood and urine specimens. Choloropheniramine and Pseudoephedrine are found in over-the-counter sinus and allergy medications. The amount of Chloropheniramine found in the liver fluid is not consistent with a level required to cause impairment.

ADDITIONAL INFORMATION

The aircraft wreckage was released to Mr. Tracy Barrus, Barrus & Steiger, Inc., Bellevue, Washington, 98015, on November 25, 1995. Mr. Barrus is representing the registered owner of the airplane.

NTSB Probable Cause

FAILURE OF THE PILOT TO MAINTAIN ADEQUATE AIRSPEED DURING TAKEOFF AND INITIAL CLIMB, WHICH RESULTED IN A STALL AND SUBSEQUENT COLLISION WITH THE GROUND. FACTORS RELATED TO THE ACCIDENT WERE: DARKNESS, THE PILOT'S IMPROPER DECISION TO TAKE OFF ON AN UNLIGHTED RUNWAY, AND THE UNEVEN RUNWAY.