NTSB Factual Report

HISTORY OF FLIGHT

On January 18, 2008, approximately 1400 Pacific standard time, a Beechcraft V35B, N4662M, broke up in flight over a vineyard, 5.7 miles west of Selma, California. The airplane was operated by the owner under the provisions of Title 14 Code of Federal Regulations, Part 91. The commercial pilot was killed, and the airplane was destroyed. Visual meteorological conditions prevailed, and an instrument flight plan had been filed. The personal flight originated at Fresno Chandler Executive Airport, Fresno, California, around 1350.

A witness reported to the National Transportation Safety Board investigator-in-charge that he heard a loud screaming noise overhead. When he looked up he observed an airplane suddenly "disintegrate," and described the wings and fuselage floating to the ground. The wreckage was located in a vineyard, and was dispersed along a 1,541-foot distance in a north-south orientation.

Federal Aviation Administration (FAA) Air Traffic Controllers reported that the pilot requested a frequency change while climbing to his assigned altitude (9,000 feet msl), and when the airplane was around 7,000 feet (msl) radar contact with the airplane was lost. No other radio communications with the pilot were reported.

Radar data files from the Fresno Terminal Area Radar Control (TRACON) were obtained and the track associated with the transponder code of 3701 was plotted. The track begins at time 1352:18 off of Fresno Chandler Executive Airport in a northwest direction at a reported altitude of 500 feet. The track proceeds to turn from a northwest direction to a southeast (approximately 110-degree heading). About 1353, at 3,100 feet, the track turns south. About 1356, at 4,700 feet, the track turns to the south-southeast. At this point the pilot requests the frequency change from Fresno TRACON. The track continues on the south-southeast heading while climbing at 900 feet per minute. At 1359:29, the track achieves its maximum altitude of 8,000 feet. The subsequent radar return, at 1359:39, indicates an altitude of 7,100 feet. This last radar return was in the vicinity of the airplane debris field. The rate of descent associated with the last radar return is 5,400 feet per minute.

PERSONNEL INFORMATION

The pilot, age 78, held commercial pilot certificates for airplane single engine, multiengine, and instrument, issued February 23, 1993. A third-class medical certificate was issued on April 19, 2007, with no restrictions. One page of the pilot's logbook was recovered from the airplane debris field. That page documented a biennial flight review dated April 29, 2006. The rest of the pilot's logbook was not located. On the pilot's April 19, 2007, medical certificate application he reported 4,500 civilian flight hours. On his April 24, 1991, medical certificate application he reported 3,500 military flight hours, and 4,100 civilian flight hours. In subsequent medical certificate applications the pilot reported having 8,000 plus flight hours.

A review of the pilot's FAA medical records revealed that he had an excessive blood alcohol level conviction on June 19, 1992, in the state of California, and failed to report it to the FAA (FAR 61.15e). The pilot surrendered his pilot certificate on November 27, 1992, and the FAA suspended his certificate for 20 days.

A relative of the pilot stated that the pilot was traveling to San Diego for a business meeting. The relative indicated the pilot had met a friend for lunch before departing and that he normally would have one vodka on the rocks at lunch. He was a social drinker.

AIRCRAFT INFORMATION

The four seat, low wing, retractable landing gear airplane, serial number D-10125, was manufactured in 1978. It was powered by a Teledyne Continental Motors IO-520-BA14, 285 horsepower engine, and equipped with a Hartzell three bladed constant speed propeller. Review of the airframe maintenance logbook showed a 100-hour inspection was performed on March 14, 2007, at a total airframe time of 2,931 hours. The engine maintenance logbook documented that an engine teardown and propeller strike inspection was performed on August 25, 2006, at a total time of 527.63 hours, and engine tach time of 2893.63. A 100-hour inspection was performed on March 14, 2007, at an engine tach time of 2,931 hours, and the time since over haul (TSOH) was 38 hours.

METEOROLOGICAL INFORMATION

Fresno Chandler Executive Municipal Airport weather observation for 1353 on January 18, 2008, was winds from 290 degrees at 3 knots; 5 statute miles visibility in haze; sky was clear; temperature was 13 degrees C; dew point was 1 degree C; and the altimeter setting was 30.20 inHg.

COMMUNICATIONS

At 1347, the pilot received his IFR clearance from Fresno approach. The pilot was cleared to Montgomery San Diego, via the Chandler published departure, vectors to Lake Hughes, then as filed. Initial climb altitude was 9,000 feet, and his radar identification squawk was 3701. At 1351, the pilot reported airborne and was given the vector of 110 degrees to fly. At 1353, he was directed to proceed direct to Lake Hughes. At 1356, the pilot requested to "...go back to alternate frequency for one minute." The controller approved the frequency change and instructed the pilot to report when he was back on frequency. At 1400, the controllers tried unsuccessfully to contact the pilot. The controllers noticed that they had lost the airplane's radar return and squawk signal from their scopes. No further transmissions were received from the pilot or airplane.

WRECKAGE AND IMPACT

The debris field was located in a vineyard, on level terrain, and ran in a north-south direction for 1,500 feet. The wreckage was fragmented into the following main component groups; engine and cockpit instrument panel, left wing, right wing, and fuselage. The empennage and ruddervators fragments were dispersed with in the debris field.

The right wing spar exhibited downward bending and a matte gray granular fracture surface. The right wing retained its flaps and aileron. The left wing spar remained bolted to the wing carry through spar; its flap and aileron were separated from the wing, along with a 6- by 2-foot middle wing skin section. All separated control cable displayed broomstrawed ends. The empennage-tail section was fragmented into 13 pieces. The left ruddervator spar was fractured at the ruddervator root; the fracture surface was matte gray and uniform in appearance with 45-degree shear lips. The right ruddervator was attached to the 256 bulkhead, which had separated from the empennage. Both elevators were separated from the stabilizer in pieces; both balance weights were located in the debris field.

The main fuselage, minus the engine, tail, and wings, was in a single piece. The forward right seat and rear passenger seats were attached to the fuselage. The left seat (pilots) was located about 3 feet away and detached from the fuselage. The control yoke, pedals, and instrument panel were not attached to the front section of the fuselage. The seat belts were not deformed or cut; the belt buckles exhibited no evidence of distress.

The engine, propeller, instrument panel, control yoke, and rudder pedals were located together. The instrument panel and firewall had wrapped itself around the accessory section of the engine. The propeller was detached from the engine but was found in line with the engine crank shaft. The control yoke arm and connecting structure was fragmented.

The pilot was located at the south end of the debris field separate from other pieces of wreckage.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot on January 19, 2008, by the Fresno County Coroner, Fresno. The autopsy report noted the cause of death to be "multiple skeletal and visceral injuries due to airplane crash." The autopsy report noted that many of the organs were absent from the body; the heart was recovered and demonstrated only "moderate" coronary artery disease. The Coroner's report stated that two tequila ‘pocket shots' (small, sealed, soft baggies containing a shot of liquor) were found in the pilot's pocket. One appeared to have been torn open and the other appeared to have been broken (burst) open.

Forensic toxicology was performed by the FAA Forensic Toxicology Research Team, Civil Aviation Medical Institute (CAMI). No blood was available for analysis. The toxicology report noted; 83 mg/dl ethanol detected in vitreous, 68 mg/dl ethanol detected in muscle, 74 mg/dl ethanol detected in brain. The report also noted diazepam, nordiazepam, oxazepam, temazepam, cyclobenzaprine, amitriptyline, and nortriptyline detected in the liver and kidney.

The pilot's FAA medical records and copies of medical records from two of the pilot's personal physicians were examined. The pilot had a history of more than 2 years of chronic groin pain, described in his personal medical records as a "constant stabbing and aching in the lumbar region and left groin/testicle/thigh." The records noted that "pain limited prolonged sitting, walking, and reclined positions" and that the pain interfered with "flying aircraft." A notation within 2 months of the accident indicated that "walking continued to be the primary aggravating factor with pain escalating to a debilitating level." In response to a pain questionnaire, the pilot had noted that whenever he experienced the pain, he felt he couldn't stand it any more, kept thinking about how badly he wanted the pain to stop, and noted that there was nothing he could do to reduce the intensity of the pain. The pilot had undergone a variety of procedures to treat the pain and had been prescribed multiple medications, including diazepam, amitriptyline, tramadol, and cyclobenzaprine, the latter first prescribed 4 days prior to the accident. He also had a history of diabetes, controlled with long-acting insulin and rosiglitazone, an oral medication. The pilot had not noted the pain, the diabetes, or the medications used to treat the conditions on his most recent application for airman medical certificate. He had noted on that application the use of only two medications, tamsulosin and meloxicam, and a history of a DUI in 1992, discovered by the FAA, and for which his pilot certificate was suspended, as a result of his failure to report the incident as required. There is no indication in the medical records that the FAA requested any details of the DUI or any records of additional evaluation or treatment surrounding the pilot's alcohol use.

NTSB Probable Cause

The pilot's failure to maintain control resulting in the in-flight break-up of the airplane due to aerodynamic overload. Contributing factors included the pilot's impairment due to multiple medical conditions and due to recent use of alcohol.