National Transportation Safety Board
Aviation Accident Final Report

 

 

Location:

Farmington, PA

Accident Number:

ERA16FA064

Date & Time:

12/11/2015, 1422 EST

Registration:

N72054

Aircraft:

BEECH A36

Aircraft Damage:

Destroyed

Defining Event:

Loss of control in flight

Injuries:

3 Fatal

Flight Conducted Under:

Part 91: General Aviation - Personal

Analysis

 

The private pilot and two passengers were departing on a cross-country flight. Witness statements and data from an onboard GPS indicated that, after takeoff, the airplane turned left and entered the downwind leg of the airport traffic pattern for the departure runway. The airplane climbed to a maximum altitude about 500 ft above ground level (agl), then entered a gradual descent as it continued downwind and entered a left base leg. Witnesses noted that the landing gear was extended. The final data points from the GPS indicated that the airplane was conducting a tight turn from the base to final legs of the traffic pattern at a low airspeed and an altitude about 200 ft agl. The airplane crashed in a heavily wooded area near a golf course. It is likely that, during the final turn, the airplane exceeded its critical angle of attack and experienced an aerodynamic stall. A passenger, who was severely burned but able to egress the airplane following the accident, advised first responders that the cabin door had opened just after takeoff.

Examination of the wreckage revealed no evidence of any mechanical malfunction of the airplane or engine prior to the accident. The forward cabin door's upper latching mechanism (hook) was not fully extended; the slot in the upper fuselage frame, which the hook engaged when the door was closed, showed no evidence of tear-outs; and the door handle mechanism was not fully in the locked position. These findings are consistent with the cabin door being open at the time of impact.

The airplane's pilot's operating handbook (POH) advised that the forward cabin door could unlatch in flight if not properly secured; this could occur during or just after takeoff. Although the door would open about 3 inches, the flight characteristics of the airplane would not be affected, with the exception of a reduced rate of climb. The POH advised that, if the door opened in flight, the pilot should "return to the field in a normal manner."

Twenty-two years before the accident flight, the airplane manufacturer published a mandatory service bulletin after receiving reports of the lower aft latch pin on the cabin door retracting in flight due to misrigging and/or vibration. When the latch pin retracted, it would force the entire door latching mechanism to reverse, allowing the door to open. This service bulletin, which had not been accomplished on the accident airplane, would have modified the forward cabin door to reduce the possibility of a cabin door opening in flight.

Toxicological testing on specimens from the pilot identified amphetamine at 0.310 ug/ml and 0.347 ug/ml in blood and 1.828 ug/ml in urine. This is well above any therapeutic range, which is less than 0.20 ug/ml. Generally, levels above 0.20 are the result of misusing amphetamine to maximize its psychoactive effects. In addition, phenylpropanolamine was detected in the pilot's urine, which suggests that he obtained the drug from non-pharmaceutical sources. An autopsy identified thickening of the heart walls and minimal coronary artery disease; however, this was unlikely to have caused acute symptoms. The thickening of the heart walls was likely caused by the increased workload related to repeated episodes of increased heart rate and blood pressure resulting from amphetamine use. It is possible that these two conditions (thickened heart and significant levels of amphetamine) combined to cause a sudden arrhythmia (a specific risk with amphetamine) which could have caused palpitations or fainting, resulting in the pilot's loss of control of the airplane. Such an event would not have left evidence that could be identified on autopsy.

It could not be determined whether the pilot was experiencing the euphoria of early phase response to amphetamine or the dysphoria of coming down from its effects. In either case, the effects are significantly impairing and affect the ability to concentrate, make safe decisions, and perform.

Regardless of the reason the door opened in flight, the airplane should have remained airworthy and controllable. Although the pilot was attempting to return to land as prescribed by the POH following a door opening event, he did not safely manage the airplane's airspeed and angle of attack and lost control of the airplane. The investigation could not determine whether the pilot's impaired judgement or an acute arrhythmia caused by his misuse of amphetamine led to his inability to safely land the airplane; however, in either case, the pilot's misuse of amphetamine contributed to the accident.

 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
 

The pilot's failure to maintain control of the airplane after a cabin door came open in flight, which resulted in the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall. Contributing to the accident was the pilot's misuse of amphetamine.

 

Findings

Aircraft

Performance/control parameters - Not attained/maintained (Cause)

Passenger/crew doors - Not specified

Personnel issues

Aircraft control - Pilot (Cause)

Illicit drug - Pilot (Factor)

Decision making/judgment - Pilot

Factual Information

 

HISTORY OF FLIGHT

On December 11, 2015, about 1422 eastern standard time, a Beech A36, N72054, was destroyed when it impacted trees and terrain shortly after takeoff from Nemacolin Airport (PA88), Farmington, Pennsylvania. The private pilot and two passengers were fatally injured. The airplane was privately owned and operated under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the personal flight, which was destined for Montgomery County Airport (GAI), Gaithersburg, Maryland.

PA88 was located on the property of the Nemacolin Woodland Resort. A witness who was staying at the resort, who viewed the airplane from his hotel room which was located on the northwest side of the runway reported that, after takeoff from runway 23, the airplane's landing gear retracted, and the airplane appeared to be departing the area; however, the airplane continued to turn as if entering the downwind leg of the traffic pattern. The landing gear extended, and the airplane began to descend. The airplane continued to descend in a turn consistent with a left base for runway 23; the witness then lost sight of the airplane behind terrain. Shortly after, he observed smoke. Another witness who was standing about 2,500 ft southeast of the runway saw the airplane pass overhead with the landing gear down. He stated that the airplane was "pretty low" and that the engine sounded normal. He saw the airplane bank to the left, and then he lost sight of it behind buildings; he then heard an impact and saw flames and smoke.

An onboard GPS recorded data for the accident flight. The recording began at 1415:57 near the airport parking area. The airplane subsequently taxied to the end of runway 23 for takeoff. Recorded GPS altitude at this time was about 1,975 ft. The takeoff roll began at 1420:18. At 1421:00, at a GPS altitude of 2,184 ft and about 2,500 ft from the departure end of the runway, the airplane began a left, climbing turn. The turn continued, and the airplane reached a maximum recorded altitude of 2,457 ft at 1421:36. At this time, its position was consistent with a left downwind for runway 23. The airplane descended as it continued the downwind leg, then began a left turn about 1422. Shortly thereafter, the airplane descended through 2,150 ft at 69 knots groundspeed. The last recorded data point was at 1422:22.

Figure 1. Plotted GPS Data – Complete Accident Flight.