LANCASTER, CA, USA
N5639S
Beech D95A
The airplane collided with a hangar during a go-around. The flight crew entered the traffic pattern and completed one touch-and-go landing. The crew requested, and the controller cleared them, for a simulated single engine full stop landing on runway 24. The controller thought that the touch-and-go approach and landing was unremarkable and perfectly normal. On the single engine full stop approach, he thought that the airplane made a short approach with the wings rocking back and fourth. The airplane looked like it was low and could possibly land short of the runway. As the airplane approached the end of the runway, it began to veer to the left (from the flight crew's perspective). The controller said it appeared to be headed directly for the control tower as it continued to drift left. The airplane stayed low to the ground and the controller had the impression that the flight crew was attempting to climb. The wing lights were continuously rocking back and fourth as the airplane continued to drift left and it crossed the dirt infield and a taxiway while still airborne. The bank angle then increased sharply to the left, and the airplane disappeared behind some hangars. The controller estimated that the airplane was 1,500 feet from the approach end of the runway when he observed a fireball and alerted rescue crews. The instructor pilot's autopsy noted undiagnosed lung cancer that had metastasized to his brain. The brain showed evidence of severe swelling, with disruption of the normal brain structure. The instructor pilot had been prescribed a pain medication (tramadol), which was found in the instructor pilot's blood at a level consistent with regular use at least at the dose prescribed. The medication is known to increase the risk for seizures, particularly in patients with other potential seizure risks. The effects of the brain swelling and the medication likely produced seizure activity in the instructor which could have significantly interfered with the aircraft controls and made it difficult or impossible for the student to have adequately controlled the aircraft.
HISTORY OF FLIGHT On January 30, 2003, at 1937 Pacific standard time, a Beech D95A, N5639S, collided with a hangar during an aborted landing at William J. Fox Field, Lancaster, California. Barnes Aviation was operating the rental airplane under the provisions of 14 CFR Part 91. The certified flight instructor (CFI) pilot and the private pilot undergoing multiengine instruction (PUI) sustained fatal injuries. The airplane was destroyed. The local instructional flight departed Fox Field about 1830. Night visual meteorological conditions prevailed, and no flight plan had been filed. The National Transportation Safety Board investigator-in-charge (IIC) reviewed a copy of recorded radio communications at the Fox Field air traffic control tower (ATCT). The flight crew entered the traffic pattern and completed one touch-and-go landing. The crew requested, and the controller cleared them, for a simulated single engine full stop landing on runway 24. The IIC interviewed the local controller in the ATCT. The controller thought that the touch-and-go landing was unremarkable. On the full stop approach, however, he thought that the airplane made a short approach. The airplane looked like it was low and could possibly land short of the runway; the wings were rocking. As the airplane approached the end of the runway it began to veer to the left (from the flight crew's perspective). The controller observed the airplane as it continued to drift left and it appeared to be heading towards the ATCT. The airplane stayed low to the ground, but the controller thought that the flight crew was attempting to climb. The wing lights were continuously rocking, and the airplane continued to drift left. It crossed the dirt and taxiway. The controller thought that they might try to land on the taxiway or ramp. He thought that it was climbing, but he was always looking down at it. The bank angle increased sharply to the left, and then hangars blocked the controller's view. He estimated that the airplane was 1,500 feet from the approach end of the runway. He observed a fireball and alerted rescue crews. PERSONNEL INFORMATION CFI A review of Federal Aviation Administration (FAA) airman records revealed that the CFI held a commercial pilot certificate with ratings for airplane single engine land, multiengine land, and instrument airplane. He held a certified flight instructor certificate with ratings for airplane single engine land, multiengine land, and instrument airplane. The CFI held a second-class medical certificate issued on February 6, 2002. It had the limitations that the pilot shall wear corrective lenses. He also had a Statement of Demonstrated Ability. It noted defective distant vision of 20/200 corrected to 20/20 bilaterally, and indicated that the pilot must wear corrective lenses for distant vision and possess glasses for near vision. No personal flight records were located for the pilot. PUI A review of Federal Aviation Administration (FAA) airman records revealed that the PUI held a private pilot certificate with ratings for airplane single engine land and instrument airplane. The pilot held a second-class medical certificate issued in January 2001. It had the limitations that the pilot must wear corrective lenses. An examination of the pilot's journal and logbook indicated an estimated total flight time of 440 hours with 29 hours in the accident airplane. AIRCRAFT INFORMATION The airplane was a Beech D95A, serial number TD-658. A review of the airplane's logbooks noted an annual inspection dated November 13, 2002. The tachometer read 4,270.2 at the last inspection; the Hobbs hour meter read 388.5 at the last inspection. The left engine was a Textron Lycoming IO-360-B1A engine, serial number RL-1647-51A. Total time on the engine at the last 100-hour annual inspection was 1,891 hours. The right engine was a Textron Lycoming IO-360-B1B engine, serial number L2106-51A. Total time on the engine at the last 100-hour annual inspection was 903 hours. COMMUNICATIONS The airplane was in contact with Fox Field ATCT on frequency 120.3. AIRPORT INFORMATION The Airport/ Facility Directory, Southwest U. S., indicated that runway 24 was 7,201 feet long and 150 feet wide. The runway surface was asphalt. The runway had runway end identifier lights (REIL) and P4L precision approach path indicator lights (PAPI). Tower personnel received no reports of problems with the lighting prior to the accident. WRECKAGE AND IMPACT INFORMATION Investigators from the Safety Board, the FAA, Beech, and Textron Lycoming examined the wreckage at the accident scene. The first identified point of contact (FIPC) was a ground scar about 65 feet long that was along a magnetic bearing of 190 degrees. White paint shards were in the ground scar and continued to the main wreckage. The ground scar stopped at the edge of the paved ramp area. The debris path was along a magnetic bearing of 190 degrees; the fuselage came to rest on a magnetic bearing of 194 degrees. The airplane came to rest in the wall between two adjacent hangars; several of the wall segments collapsed. The hangar door sustained mechanical and thermal damage. Fire damaged the hangar, and destroyed another airplane that was in the hangar. The right wing separated outboard of the engine and was by the hangar door structure. The top half of the vertical stabilizer and rudder were a few feet outside the front of the hangar. The right propeller separated and was in the adjacent hangar. It did not sustain any thermal damage. MEDICAL AND PATHOLOGICAL INFORMATION The FAA Toxicology and Accident Research Laboratory performed toxicological testing of specimens of the pilots. The results of analysis of the specimens of the CFI contained no findings for cyanide in blood or ethanol in urine. It had a finding of 21% carbon monoxide detected in blood. The report contained the following findings for tested drugs: Bisoprolol detected in blood and urine; Tramadol present in urine; 0.401 (ug/ml, ug/g) Tramadol detected in blood; and 392.4 (ug/ml, ug/g) Salicylate detected in urine. The results of analysis of the specimens of the PUI contained no finding for cyanide in blood or ethanol in urine. It had a finding of 28% carbon monoxide detected in blood. The report contained the following findings for tested drugs: Ephedrine detected in urine; Pseudoephedrine detected in urine; and Phenylpropanolamine detected in urine. The Los Angeles County Coroner completed autopsies of the CFI and PUI. The CFI's autopsy report noted, in part "there are chronic changes of brain swelling associated with metastatic adenocarcinoma. This is from the lung nodules which are of adenocarcinoma. The role that the metastatic carcinoma may have played in the causation of the accident is not clear, and the pathologic findings can be correlated with the clinical situation." A forensic neuropathology consultant's report noted, in part: "The entire brain is swollen, left greater than right side, to severe degree anteriorly and moderately severe degree posteriorly and inferiorly in the hemispheres. Examination of the undersurface of the cerebellum reveals some mechanical distortion of the right greater than left cerebellar hemisphere, but there is also evidence of tonsillar herniation laterally with mild softening and partial granular degeneration of the portion of the tonsillar/biventer area medial to the grooving. Thus, there is evidence of herniation syndrome, both at the uncus and cerebellar tonsillar region. Uncal herniation is relatively mild, and cerebellar tonsillar herniation is moderate." A review of the instructor pilot's personal and FAA medical records by the Safety Board Medical Officer indicated that the he had been diagnosed with rheumatoid arthritis (of which the FAA was aware), and had hand pain. That review noted that the instructor pilot had been on sulfasalazine (a prescription anti-rheumatic medication), celecoxib (a prescription anti-inflammatory medication), one coated aspirin a day, rabeprazole (a prescription stomach-acid reducing medication), a prescription medication for high blood pressure combining bisoprolol and hydrochlorothiazide, and tramadol, a prescription medication used for the management of moderate to severe pain. There was no indication in that review that the instructor pilot or his physicians were aware of the lung cancer found on autopsy. Prescribing information for tramadol warns that seizures have been reported in patients receiving tramadol. In one study (Gardner JS, Blough D, Drinkard CR, Shatin D, Anderson G, Graham D, Alderfer R. Tramadol and seizures: a surveillance study in a managed care population. Pharmacotherapy. 2000 Dec;20(12):1423-31), seizures were noted in 0.9% of patients after receiving their first tramadol prescription; the same study noted increased risk in patients with other risk factors for seizure (e.g. head trauma, stroke, alcohol withdrawal, previous history of seizures, etc.). TESTS AND RESEARCH Investigators examined the wreckage at Aircraft Recovery Service, Littlerock, California, on February 1, 2003. LEFT ENGINE Investigators removed the engine, placed it on a table, and removed the top spark plugs. All spark plugs were clean with no mechanical deformation. The spark plug electrodes were gray. A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder head. Investigators manually rotated the engine. The crankshaft rotated freely, and the valves moved approximately the same amount of lift in firing order. The fuel pump plunger moved up and down, and the gears in the accessory case turned freely. Investigators obtained thumb compression on all cylinders in firing order. The magnetos sustained thermal damage and were not tested. The oil sump screen was clean and open. The oil screen was clean. The governor screen was clean. Both blades on the left propeller exhibited leading edge gouging and twisted toward low pitch. RIGHT ENGINE The right propeller separated from the right engine behind the flange. The fracture surface was on a 45-degree angle to the longitudinal axis of the crankshaft. The right propeller came to rest in an adjacent hangar. The wall between the two hangars sustained mechanical damage and collapsed down onto the nose section of the airplane. The separated right propeller did not sustain thermal damage. Investigators removed the right engine, placed it on a table, and removed the top spark plugs. All spark plugs were clean with no mechanical deformation. The spark plug electrodes were gray. A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder head. The right engine sustained mechanical damage and would not rotate. Both propeller blades exhibited leading edge gouges, and the tips of both propellers fractured and separated along jagged planes. The airframe manufacturer's representative determined that the landing gear was down. The elevator trim measured 1.5 inches. The representative determined this equated to a 0-degree or neutral setting. The rudder trim actuator measured 1 7/16 inches, which the representative equated to 5-degree right tab deflection. Owner's Manual The owner's manual provided information on the airplane, its systems, and procedures. One section described a balked landing. It stated that the decision to go around should never be delayed until the airplane was near the ground in the landing position. It noted that the margin of safety would be optimized with more altitude and airspeed remaining in the approach. The emergency procedures section discussed single engine operation. It noted that 84 mph was the minimum indicated airspeed (IAS) at which the pilot could maintain directional control in the takeoff configuration, with one engine inoperative, and full takeoff power on the operating engine. It pointed out that this was the minimum speed for control, and was below the speed at which the airplane would climb. The emergency section on a single engine landing noted that the pilot should allow a larger safety margin during the pre-landing pattern and final approach. The safety margin came from maintaining a higher airspeed, slightly higher pattern and final approach altitudes, and a wider pattern that eliminated the need for any steeply banked turns. These procedures provided line up with the runway further out. This would allow more time to correct for wind drift, stabilize the final approach speed and rate of descent, and judge more accurately the use of the flaps and landing gear. This also allowed easing of power on the good engine a little sooner, which allowed a reduction in rudder trim. ADDITIONAL INFORMATION The operator did not submit a Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2). The IIC released the wreckage to the owner's representative.
a loss of aircraft control due to the instructor pilot's incapacitation by seizure activity as a result of his undiagnosed cancer, and his use of a medication that can increase seizure risk.
Source: NTSB Aviation Accident Database
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