NTSB Factual Report

HISTORY OF FLIGHT

On December 17, 2000, at 1821 central standard time, a Beech BE-23, N2324J, was destroyed when it impacted hilly, wooded terrain near Rolla, Missouri. The 14 CFR Part 91 business flight had departed Spirit of St. Louis Airport (SUS), Chesterfield, Missouri, at 1700, en route to Tulsa, Oklahoma, for a fuel stop, with Odessa, Texas, as the final destination. The pilot received fatal injuries. Night visual meteorological conditions prevailed and no flight plan was filed.

A witness reported the pilot flew from Odessa, Texas, to SUS in a Cessna 182 that departed at 0820 on December 17, 2000. Two other pilots were on board, one of which was a student pilot who intended to purchase N2324J. The student pilot planned to subsequently lease back the airplane to the accident pilot who was a fixed base operator (FB0) in Odessa. The purpose of the flight to SUS was to perform a pre-buy inspection of N2324J before flying it back to Odessa that same day. The accident pilot and the other pilots arrived at SUS about 1430 to 1500 to perform the pre-buy inspection of N2324J.

A witness reported the accident pilot inspected N2324J's airframe and engine logbooks. During the airplane inspection, the pilot expressed concern about the welds on the ends of the muffler shroud. The accident pilot completed the pre-buy inspection of N2324J.

The owner of N2324J reported the accident pilot arrived at 1430. He reported the accident pilot inspected the airplane while it was in the hangar and completed the pre-buy inspection by 1500. He reported all three pilots went to lunch before departing. He reported N2324J was taxied to the Jet Corp ramp where it was topped off with 40 gallons of fuel prior to departing.

The pilots in the Cessna 182 reported the accident pilot departed in N2324J about 1700. They departed in the Cessna 182 about 5-7 minutes later. They were not able to make radio contact with N2324J once they departed. One of the pilots reported that they knew they would out run N2324J since their ground speed was about 90 kts, and N2324J's ground speed was about 65-70 kts due to a 35 kts headwind. The Cessna 182 landed in Tulsa, Oklahoma, for fuel. It departed and refueled in Abilene, Texas, before proceeding to Odessa, Texas, where they arrived about 0200 on December 18, 2000. The pilots were unaware that N2324J had not arrived at Tulsa.

Rolla, Missouri, is located about 70 nautical miles from SUS on a heading of 230 degrees magnetic. There were no radio transmissions from N2324J recorded by the FAA Air Traffic Control. Radar data indicated that N2324J was flying in a southwesterly direction until about 1800:25, when the airplane turned to the northwest.

The radar data indicated the airplane's altitude remained between 8,700 and 8,500 feet mean sea level (msl) from the period between 1800:25 and 1808:52, but the airplane's heading was inconstant, first heading to the northwest, then heading to west and then to the south, and making a 360 degree turn before heading south again. The radar data indicated the airplane's altitude started descending from 8,500 feet msl at 1809:04 to an altitude of 2,000 feet msl recorded at 1821:08, which was the last radar return recorded. Between 1809:04 and 1821:08, the radar data indicated the airplane's flight path was a series of inconstant descending turns that took the airplane in an easterly direction. The last radar return was approximately .5 nautical mile from the accident site. (See Radar Plot)

A witness reported that on December 17, 2000, at 1830, a, "Plane or aircraft made a low pass over my house from the north and back to the north close to the house. I was watching T.V. I told my wife who is that crazy person flying that plane? I went out on the front porch and watched the aircraft make two short clock wise turns to the east of my house very low to the ground. Then I went to the back porch of my house and watched the plane go to the east. It made a steady climb over the timberline, and a sudden descent out of sight. I came back in the house and told my wife I think that the plane went down." The witness reported the incident to the highway patrol.

A search for N2324J was initiated on December 18, 2000. The airplane was located in a heavily wooded ravine near Rolla, Missouri, on December 21, 2000.

PERSONNEL INFORMATION

The pilot held a commercial pilot certificate with single-engine land and multi-engine land, and instrument ratings. He held a certified flight instructor certificate with privileges to instruct in single engine land and multi-engine land airplanes. He held a Second Class medical certificate. The pilot had a total of about 2,426 hours of flight time as of May 1, 2000. The pilot's flight logbooks were not recovered.

AIRCRAFT INFORMATION

The airplane was a single engine Beech BE-23, serial number M275. The airplane seated four and had a maximum gross weight of 2,300 pounds. The engine was a 160 horsepower Lycoming O-320-D3B engine. The last annual inspection was conducted on August 16, 2000. The airplane had flown 6 hours since the last inspection and had a total time of 2,082 hours.

The previous owner of the airplane reported he had numerous repairs made to the airplane during the annual inspection in May 1999. The aircraft logbooks indicated the airplane flew 17.1 hours between the 1999 annual inspection and the 2000 annual inspection. The pilot reported he flew the airplane about 6 hours since the annual inspection in August 2000. He reported he had not flown the airplane in cold weather since the annual inspection.

The aircraft logbooks indicated the muffler was inspected in accordance with Airworthiness Directive (AD) 64-06-01 on May 21, 1999, during the annual inspection. Maintenance records indicated the muffler was replaced on November 26, 1973. The maintenance records indicated the cabin heater and muffler weld assembly had been "checked for leaks and deteriation" during the 1999 annual inspection, and they were found to be "OK."

METEOROLOGICAL INFORMATION

The 1753 weather observation at the Rolla/Vichy Regional Airport (VIH), Rolla, Missouri, was winds 220 degrees at 7 knots, 10 miles visibility, clear skies, temperature 13 degrees F, dew point 3 degrees F, altimeter 30.10.

The pilot of the Cessna reported the headwind at 8,500 feet was approximately 35 knots.

WRECKAGE AND IMPACT INFORMATION

The airplane impacted the ground in a steep nose down attitude on a heading of 280 degrees magnetic. There was little damage to the surrounding trees. The propeller and engine were buried in the ground with the back of the engine being about 6 inches below ground level. The cabin, fuselage, left and right wings, and empennage remained attached and were found crushed and buckled at the impact site. The leading edges of the left and right wings exhibited leading edge crush. The pilot's seatbelt was found unfastened.

Cable continuity was confirmed to the flight controls.

The propeller blades exhibited "S" bending, leading edge gouges and chordwise scratching. Broken tree branches and limbs were found that exhibited propeller slashes and gray paint transfer.

Engine continuity and thumb compression could not be obtained because the crankshaft was bent approximately five degrees up and towards the number two cylinder. The left magneto was tested and produced spark at all distribution points. The right magneto could not be tested due to impact damage. The carburetor was broken from its mounting. The fuel pump could not be tested due to impact damage, but a trace amount of fuel was found. The spark plugs condition was consistent with normal operation.

The muffler/heater assembly was found crushed and laying on top of the engine at the wreckage site. It was removed and sent to the National Transportation Safety Board (NTSB) for metallurgical examination.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot on December 23, 2000, at the Boone/Callaway County Medical Examiner's Office.

A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aeromedical Institute. The report concerning the pilot indicated the following results:

Carbon monoxide: Not performed.

Cyanide: Not performed.

No ethanol detected in the kidney or liver.

No drugs detected.

The carbon monoxide test could not be performed due to an inadequate blood sample.

TESTS AND RESEARCH

The NTSB Materials Laboratory Factual Report stated the muffler and heater muff assembly contained severe crushing deformation and was fractured into two pieces. A microscopic examination of the muffler portion revealed the internal wall exhibited oxidation damage. The report stated, "Many areas of the muffler fracture showed oxidation damage that penetrated through the wall. The oxidation damage areas on the fracture appeared black, consistent with a pre-existing fracture that was exposed to the environment for an extended period of time." It further stated, "By visual estimate, the total combined length of the oxidation damage areas that penetrated through the wall was at least 20% of the circumference of the body of the muffler.

The NTSB report stated, "The examination of the fractures from the heat exchanger collector tube showed evidence of minor tinting which is consistent with short-term (post crash) exposure to heat." It stated, "The outer layer of the tube had a decaburized layer, typical of steel exposed to high temperature and the environment for an extended period of time. The fracture surface of the heater muff exhibited no evidence of tinting."

The NTSB report stated the welds at the muffler end caps were intact and showed no cracks. (See Materials Laboratory Factual Report)

ADDITIONAL INFORMATION

The FAA issued an Aircraft Circular (AC) bulletin, "AC 20-32B, Carbon Monoxide (CO) Contamination in Aircraft-Detection and Prevention," on November 24, 1972. The AC stated, "Many light aircraft cabins are warmed by air that has been circulated around the engine exhaust pipes. A defect in the exhaust pipes or cabin heating system may allow carbon monoxide to enter the cockpit or cabin. The danger is greatest during the winter months and any time the temperature is such that use of the cabin heating system becomes necessary and windows and vents are closed."

Parties to the investigation included the Federal Aviation Administration, the Raytheon Aircraft Company, and Textron Lycoming.

The airplane wreckage was released to Universal Loss Management. The muffler and heater assembly was released to Pruett Aviation.

NTSB Probable Cause

The pilot's inadequate preflight during the pre-buy inspection, the pilot's incapacitation due to carbon monoxide, and the fractured muffler.