History of Flight
On March 1, 2014, about 1215 eastern standard time, a Beech F33A, N7203E, was destroyed when it collided with trees and terrain near Lumberport, West Virginia. The private pilot was fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the local personal flight, which departed Fairmont Municipal Airport (4G7), Fairmont, West Virginia, and was conducted under 14 Code of Federal Regulations Part 91.
A witness, standing in a valley just beyond a small mountain where the accident occurred, stated he did not see the airplane prior to the accident, but heard an engine sputtering, then go to full power. He subsequently heard trees and branches breaking, and metallic sounds, then looked up to see trees and branches falling and airplane debris descending down the side of the mountain. He then proceeded up the mountain where he saw the remnants of the airplane.
Radar information revealed the airplane departed 4G7 (elevation 1,032 feet msl) about 1140. It headed west-southwest, initially climbing to 3,500 to 3,600 feet msl by 1143, but after 1148, continued outbound at 3,300 to 3,400 feet. At 1203, near the Ohio border, the airplane turned right and reversed course, tracking eastbound back toward 4G7. It maintained altitudes between 3,300 and 3,400 feet until 1210, when it climbed to 3,500 feet. By 1211:40, it climbed to 4,000 feet; by 1212:51, descended to 3,100 feet; then climbed again to 3,500 feet by 1213:52, but then descended and maintained between 3,400 and 3,200 feet until 1214:49, when it climbed again to 3,600 feet. It subsequently began a final descent; at 1215:08, the airplane was at 2,800 feet; at 1215:12, at 2,600 feet; and at 1215:17, last radar contact, at 1,800 feet. There were no major course deviations during the descent.
Personnel Information
The pilot, age 68, held a private pilot certificate with airplane single engine land and instrument-airplane ratings. His latest FAA third class medical certificate was issued on November 1, 2012. At that time, he indicated 1,550 total flight hours, with 30 hours in the previous 6 months. No logbook was located at the accident site; logbooks provided by the pilot's family only listed flights through 1997.
Aircraft Information
The single-engine metal airplane was powered by a Continental IO-520-series engine driving a three-bladed metal propeller. The latest annual inspection was completed on January 4, 2014, at which time the airplane had operated 1,995.7 hours, and the engine 897.0 hours since new.
Meteorological Information
The weather, recorded at an airport 9 nm to the south, included winds from 040 degrees true at 15 knots, gusting to 24 knots; overcast skies at 7,500 feet; 10 miles visibility; temperature 45°F; dew point 27°F; and an altimeter setting of 30.18 inches Hg.
Wreckage and Impact Information
The impact sequence commenced in trees just west of a ridgeline near 39°25.44'N, 080°26.78'W at an elevation of about 1,370 feet. Severed hardwoods, some up to 18 inches in diameter, were sheared in an approximately 15-degree descending path after the first tree strikes. The downward path, heading about 130 degrees magnetic, ended in a large ground scar on the ridgeline. Beyond the scar, descending beyond the ridgeline, were the scattered remnants of the highly fractured airplane. The largest piece, part of the cabin roof attached to the right wing, was wrapped around a tree about 100 feet below the ridgeline. The most distant object, the engine, came to rest about 150 yards from the initial impact point and 150 feet below the ridgeline.
The majority of the airplane was accounted for at the site; however, due to an incoming winter storm, documentation was suspended. Prior to departure, all three propeller blades were located separate from the hub: one exhibited torsional bending, leading edge damage and a separated tip; one exhibited torsional bending and leading edge damage near the tip; and the last exhibited a lesser degree of bending. The separated panel containing the three engine controls was also located; the mixture was in, and the propeller rpm and throttle were mostly pulled out; however, due to damage, actual control positions at impact could not be determined.
The wreckage was recovered after sufficient snow melt and taken to a storage facility for further documentation. Evidence of all flight control surfaces was confirmed. Flight control continuity could not be completely determined due to the fractured nature of the wreckage. The rudder control cables were continuous from the cockpit to the aft rudder bellcrank that was separated. The aileron flight control cables were continuous from the cockpit to each respective wing aileron outboard bellcrank, but the left and right aileron pull cables were separated from their respective aileron control bellcrank, separated in the cockpit area, and the aileron balance cable was separated at the right aileron outboard bellcrank and at the rear spar carry-through. The cable separations exhibited splayed ends and individual filaments consistent with tensile overload. Elevator flight control cable continuity could not be determined.
The engine was severely impact damaged, and the exhaust system exhibited bending and folding consistent with heat having been applied at impact. Crankshaft continuity was confirmed, and top spark plugs were gray in color. Neither magneto was recovered. The fuel pump rotated freely by hand. The fuel manifold valve diaphragm was intact. The retaining nut and plunger were tight and secure. The fuel screen exhibited a minor amount of dirt, and the fuel manifold valve cavity had impacted dirt. Three of the fuel nozzles were fractured or bent and could not be removed; the other three were free of debris. The throttle body/metering unit exhibited impact damage; the throttle and mixture control arms were bent but moved freely from stop to stop. The throttle plate moved freely, and the fuel screen was free of debris. The oil pump was disassembled with no preexisting anomalies; the internal element oil filter was absent of metal.
Medical and Pathological Information
An autopsy was performed on the pilot at West Virginia University, Morgantown, West Virginia, where the cause and manner of death were noted as "Undetermined." The autopsy was limited by the degree of damage to the body; no heart or brain was available for examination. Toxicological testing was hampered by a lack of blood or other body fluids. Initial testing by the medical examiner revealed mirtazapine and ethanol in muscle at 0.07%. Subsequent testing at the FAA's Civil Aerospace Medical Institute found amlodipine, mirtazapine, and valsartan, but no ethanol in tissue specimens.
A Medical Factual Report was produced by the NTSB Chief Medical Officer, based on the pilot's medical certification file, FAA medical case review, toxicology results, autopsy report, personal medical records, and witness statements. Personal medical records were subpoenaed from the pilot's physician, who was also the pilot's FAA-designated Aviation Medical Examiner (AME), and produced only five pages of records through October 12, 2009. The pilot had a history of hypertension, depression, and anxiety, and had suffered a stroke in 2008. The physician prescribed multiple medications for those conditions in 2008 and 2009, including two medications the FAA considered disqualifying for pilots. Neither the pilot nor the AME reported these conditions or their treatment to the FAA when the pilot obtained aviation medical certificates from the same physician/AME in 2010 and 2012.
As noted in the Medical Factual Report, "In a study that followed patients after a stroke that left them with no or minimal disability, the risk of recurrent major stroke was 14% and the risk of death from any cause was 32% by 10 years later. Recurrent minor stroke, diabetes, heart attack, and hypertension significantly increased the risk of recurrent major stroke. ... Current recommendations for treatment following transient ischemic attacks and ischemic strokes are designed to decrease the likelihood of a recurrent event. Guidelines include ongoing treatment with antiplatelet medications such as aspirin or clopidogrel, evaluation and aggressive treatment of cholesterol, and careful management of hypertension and diabetes." There were no records or indication from the family as to who prescribed the pilot's current medications or who might have been treating him. Witnesses reported that the pilot was slurring his speech within the two weeks preceding the accident and possibly had suffered mini-strokes, but family members denied knowledge. They also noted the pilot had recently retired and was looking forward to moving south.