Pilot Debrief

BEECH V35 near Oklahoma City, OK — 2009-07-25

Final reportCEN09FA462
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Date
2009-07-25
Location
Oklahoma City, OK, USA
Airport
PWA
Aircraft
BEECH V35
Registration
N9112S
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Climb

Probable cause

The pilot’s decision to operate an airplane with known deficiencies, and the loss of engine power during climb for undetermined reasons.

NTSB narrative

The airplane had a previous history of in-flight engine stoppages, and the engine lost power twice within the week before the accident. The pilot did not have his mechanic investigate the cause of those events, as he believed when the engine lost power the airplane was in a fuel cross feed position, and all he had to do was to switch to a main fuel tank. On the day of the accident the airplane was two miles from the airport after departure when the pilot reported a loss of engine power to air traffic controllers. The pilot executed an off-airport emergency landing to a congested area, adjacent to a major six-lane thoroughfare. The airplane was substantially damaged when it impacted a tree and the concrete base of a light pole, during the emergency landing. The engine was recovered from the wreckage and installed in an engine test cell. It started on the first attempt and ran at full throttle with no anomalies noted. A postexamination of the other airplane systems showed no anomalies. The pilot had been treated for anxiety, depression, high blood pressure, and obstructive sleep apnea, among other significant conditions. He had been on multiple medications at the time of the accident including at least an antidepressant, a blood thinner and a potentially impairing prescription medication often used for the treatment of chronic pain. The pilot denied any medical conditions or the use of medications in his most recent application for an airman medical certificate. It was not possible to conclusively determine whether distraction or impairment due to his medical conditions or to medication use may have played a role in his decision-making following the loss of engine power. The pilot’s fatal injuries were likely a result of the impact between his chest and the control yoke. It could not be conclusively determined the extent to which the forward cabin structure and the control yoke in particular were moving aft relative to the rest of the cabin structure following the primary impact with the ground, but it is possible that the likelihood or severity of the pilot’s impact with the control yoke would have been reduced through the availability and use of a shoulder harness.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot should have grounded the aircraft after previous engine failures.

NTSB coding

Evidence available

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

Docket documents26

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