Pilot Debrief

BEECH 95 B55 (T42A) near Fredericksburg, VA — 2016-08-12

Final reportERA16FA288
Sign in to save
Date
2016-08-12
Location
Fredericksburg, VA, USA
Airport
EZF
Aircraft
BEECH 95 B55 (T42A)
Registration
N128VB
Category
Airplane
Highest injury
Fatal
Fatalities
6
Phase of flight
Approach

Probable cause

The pilot(s) failure to maintain adequate airspeed during an attempted go-around, which resulted in an exceedance of the airplane's critical angle of attack and an aerodynamic stall.

NTSB narrative

The private pilot, who was seated in the left front seat, was making a cross-country flight in the twin-engine airplane with five passengers on board; the passenger seated in the right front seat was a commercial pilot. Shortly after departing, the pilot contacted air traffic control and requested visual flight rules flight following services to the destination airport. A variable quartering headwind prevailed about the time the airplane approached the destination airport's 2,999-ft-long runway, with an approximate headwind component of about 8 knots. Given the airplane's estimated landing weight and the prevailing weather conditions, the airplane's calculated landing distance was between 1,280 and 1,850 feet. Review of recorded data showed that the airplane crossed the runway threshold for landing at an altitude about 40 ft above the ground and at an estimated airspeed of 95 knots, about 9 knots faster than the airframe manufacturer's recommended final approach speed for its estimated weight. Witness interviews, surveillance video, and recorded data showed that the airplane touched down and bounced several times near the mid-point of the runway. The airplane then started to climb at an estimated airspeed of 68 knots, which was well below the balked landing climb speed of 90 knots, and near the published stall speed of 73 knots with the landing gear and flaps extended. The airplane made a shallow left turn and climbed to an altitude of about 100 ft above ground level. During the climbing turn, airplane's speed further decreased to an estimated 62 knots before it entered an aerodynamic stall and descended to impact terrain. Examination of the airframe and engines did not reveal any evidence of preimpact mechanical malfunctions that would have precluded normal operation. Postaccident weight and balance calculations indicated that the airplane was below its maximum gross landing weight and that the center of gravity was within limits. The pilot did not hold a valid Federal Aviation Administration medical certificate and had a history of significant medical issues, including hypertension, high cholesterol, diabetes, and heart disease; however, it is unlikely that the pilot's hypertension or high cholesterol contributed to the accident. Toxicology testing identified zolpidem, a prescription sleep aid, at below-therapeutic levels; because zolpidem undergoes postmortem redistribution and the tested blood came from the heart, the antemortem level was likely lower than the measured level. As a result, it is unlikely that the sedative effects from the zolpidem contributed to the accident. The pilot's diabetes could have contributed to the accident if he experienced acutely low blood sugar, which causes psychomotor slowing and eventually loss of consciousness, or had difficulty operating the airplane due to diabetic neuropathy. Further, an acute cardiac event in either the pilot or the pilot-rated passenger, who also had significant heart disease, could have contributed to the accident; however, the investigation was unable to determine whether any of the pilots' medical issues contributed the accident, and it is unlikely that both suffered an acute medical event at the time of the landing and subsequent loss of control during the go-around attempt. It could not be determined which of the two pilots was manipulating the controls and flying the airplane during the landing approach and subsequent go-around, as both the pilot (airplane owner) and the pilot-rated passenger were seated at a fully functional set of flight controls.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have aborted the landing earlier to avoid collision.

NTSB coding

Evidence available

  • Video
  • Photos
  • 18 docket documents
View NTSB final reportView NTSB docket

Docket documents18

Related mishaps