Beech 58 near Ocala, FL — 2019-10-31

Probable cause

The pilot’s failure to maintain control of the airplane due to an acute medical event and/or his use of impairing medications.

NTSB narrative

After experiencing an issue with a fluctuating fuel transducer on the right engine, the pilot hired a mechanic, who removed the fuel flow transducers from both engines and reinstalled them on the opposite engine to determine if there was an instrument indication problem or a fuel flow sensor issue. After performing the maintenance, the pilot and mechanic performed several ground runs of the engines without incident. They then departed on a local flight. Review of air traffic control communications revealed that the pilot initially taxied to the wrong runway, and after takeoff, failed to acknowledge multiple calls from the controller, did not follow the controller’s instructions, and thought that he was flying west when he was flying toward the east. About 2 minutes after takeoff, a transmission was received from the accident airplane requesting to return to the airport. The airplane impacted a four-lane divided highway and was consumed by a postcrash fire. Examination of the airplane, both engines, and their respective fuel transducers revealed no mechanical discrepancies that would have precluded normal operation. Autopsy of the pilot revealed severe abdominal aortic atherosclerotic disease, which increased his risk for an extra-cardiovascular event such as a stroke. Toxicology testing detected the impairing medication diazepam and its metabolite at the lower end of its therapeutic range in the pilot’s chest blood. Toxicology testing also revealed that the primary psychoactive compound of marijuana, THC, was detected in the pilot’s blood just above the laboratory’s detection limit. The THC concentration did not suggest recent use and it is unlikely that the pilot’s use of marijuana contributed to the accident. The circumstances of the accident indicate that the pilot did not perform in a manner consistent with his level of skill and experience, and it is likely that his loss of control was the result of physiological impairment; however, whether his impairment was the result of an acute medical event and/or his use of impairing medications could not be determined based on the available information.

Analysis

Primary failure mode

Human factors

First missed decision gate

Pilot failed to acknowledge ATC instructions to turn west after takeoff.

NTSB coding

• Medical event · Initial climb
• Impairment / Incapacitation

Evidence available

• Video
• Photos
• 18 docket documents

Docket documents18

• FCT AIR TRAFFIC CONTROL COMMUNICATIONS CHRONOLOGICAL SUMMARY EXCERPT (COURTESY OF FAA)atc
• PARTY FORMS_TEXTRON AND CONTINENTALform
• WRECKAGE RELEASE AND EVIDENCE CONTROL FORMSform
• AIRPLANE MAINTENANCE LOGBOOK EXCERPTSother
• EMAIL COMMUNICATION WITH PRIMARY MAINTENANCE FACILITYother
• FAA CONTROL TOWER RECORDING GROUND CONTROL (COURTESY OF FAA)other
• FAA CONTROL TOWER RECORDING LOCAL CONTROLLER (COURTESY OF FAA)other
• NTSB RECORD OF CONVERSATIONSother
• POLICE NARRATIVE (INCLUDES WITNESSES)other
• PHOTO ARRAY_ACCIDENT SITE AND DAMAGEphotos
• ELECTRONIC DEVICES SPECIALIST'S FACTUAL REPORTreport
• ELECTRONIC DEVICES SPECIALIST'S FACTUAL REPORT - ATTACHMENT 1report
• MEDICAL CASE REVIEW_FACTUALreport
• TOXICOLOGICAL REPORTS_PILOT AND A&P MECHANIC PASSENGERreport
• AIRPORT SECURITY CAMERA VIDEO_PRIOR TO TAXIvideo
• AIRPORT SECURITY CAMERA VIDEO_TAXI AND TAKEOFFvideo
• CAR CAMERA VIDEO OF ACCIDENTvideo
• NTSB VIDEO STUDYvideo