Pilot Debrief

BEECH 58 near Galt, CA — 2022-09-04

Final reportWPR22FA332
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Date
2022-09-04
Location
Galt, CA, USA
Aircraft
BEECH 58
Registration
N142DR
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Maneuvering

Probable cause

The certified flight instructor's failure to maintain control of the airplane and inadequate supervision of the flight, which resulted in an aerodynamic stall/spin from which he could not recover.

NTSB narrative

The pilot under instruction and the certified flight instructor (CFI) departed in the multi-engine airplane to conduct training. Radar data indicated that they proceeded to multiple airports and performed traffic pattern work including takeoff and landings. After departing the last airport, they performed two 360° turns and one power off stall task. The airplane again slowed and recorded engine data indicated that, while the critical engine’s speed was reduced, the other engine’s speed was increased, consistent with performing a Vmc demonstration. During a Vmc demonstration, power is reduced on the critical engine (left) and the airplane is recovered before loss of directional control or stall. As the airspeed decreased, the airplane entered a rapid descent with a continuous left-hand turn that was observed by witnesses as it was spinning, not nose down, with a flat attitude until water impact. Impact signatures were consistent with a slightly nose-low, near-flat attitude. Postaccident examination of the engines and airframe did not reveal evidence of any mechanical malfunctions or anomalies that would have precluded normal operation of the airplane. Positive identification of who was on the controls during the Vmc demonstration could not be determined given the available evidence.

Analysis

Primary failure mode
Human factors
First missed decision gate
Conducting engine-out training maneuvers at low altitude and speed.

NTSB coding

Evidence available

  • ADS-B / radar
  • 14 docket documents
View NTSB final reportView NTSB docket

Docket documents14

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