History of Flight
On June 13, 2018, at about 0907 eastern daylight time, a Beech 58, registration N218BL, was destroyed in an accident near Springfield Township, New Jersey. The private pilot and passenger were fatally injured. The flight was operated as a Title 14 Code of Federal Regulations Part 91 personal flight with the purpose of picking up a patient and their spouse for a volunteer medical transport flight from Barnstable Municipal Airport-Boardman/Polando Field (HYA), Hyannis, Massachusetts, to Northeast Philadelphia Airport (PNE), Philadelphia, Pennsylvania.
According to a transcript of communications with the United States Air Force (USAF) McGuire Field (Joint Base McGuire Dix Lakehurst) Airport (WRI) radar approach control, around 0858, an occupant aboard the accident airplane contacted clearance delivery and received an amended instrument flight rules (IFR) clearance to HYA, which included the requirement to climb and maintain 2,000 ft after takeoff from South Jersey Regional Airport (VAY), Mount Holly, New Jersey. It could not be determined if the pilot or the pilot-rated passenger was operating the radios. At 0859:43, the controller asked if the flight was ready, and an occupant responded affirmatively. Around 0900, a military aircraft about 12 nautical miles east-northeast of VAY reported cloud bases around 300 ft, then about 30 seconds later, reported being on top of the first cloud layer at about 2,500 ft mean sea level (msl).
The flight was released for departure around 0901, and at 0903:48, VAY security video captured the airplane departing from runway 8. ADS-B data showed the airplane climbing through 150 ft msl at 0903:56. The flight proceeded approximately runway heading while climbing at about 105 knots (best rate of climb), then turned left onto a north-northeasterly heading, climbing to about 500 ft msl. The climb stopped around 0904:24, and the airplane descended and began accelerating. At about 0904:32, while flying on a north-northeasterly heading, an occupant told the controller that the flight was "…through five hundred for two thousand"; ADS-B data showed the airplane at 465 ft msl at that time.
The flight continued on the north-northeasterly heading until about 0904:56, then turned right onto a northeasterly heading. Although the early portion of the ground track was consistent with departure instructions, the altitude profile was not. At 0905:10, a second climb began, and at 0905:21, while flying about 1,100 ft msl, the controller asked the pilot for the ceiling base, and an occupant asked the controller to repeat the question. The controller repeated "say bases," but the occupants did not reply. At 0905:55, the airplane leveled at 1,400 ft msl, contrary to departure instructions, and about 5 seconds later, the controller asked the pilot to state flight conditions at departure; the reply was "IFR." The airplane was in a level climb attitude, about 150 knots, in a 10° right bank. Over the next 20 seconds, the airplane began a right descending turn with the bank angle increasing to greater than 80°. At 0906:25, below 500 ft msl, the controller broadcast the airplane's call sign; the response from the airplane was not clear but sounded like "copy." No further transmissions were received.
At 0906:27, the airplane entered a steep climb to a maximum altitude of 1,700 ft at 0906:35. Airspeed decelerated during the climb and approached the published wings-level, 1-g stall speed of 84 knots. At that time, the airplane was in a 30° right bank; the pitch attitude lowered abruptly, and the airplane rolled into a 60° left bank, followed by a right bank. The last unvalidated ADS-B target was about 300 ft south-southwest of the accident site. At 0907:14, the controller broadcast that radar contact was lost.
A witness about 800 ft south of the accident site heard the airplane approaching from the east but could not see it due to low cloud ceiling. The sound circled behind him, decreased for about 12 to 15 seconds, and returned from the northwest. He first saw the airplane to the north, flying away with the left wing slightly lower than the right. The engines were very loud and constant. He heard the impact as a "thud" and drove to the site to assist. Another witness about 1,450 ft south reported a low cloud ceiling and gentle breeze. She heard an airplane flying exceptionally low around 0900. She saw the airplane make a pass and turn toward the northern fence, then come down at a steep angle, followed by two "thumps" as it hit trees and then the ground.
Personnel Information
The pilot's most recent flight review and instrument proficiency check (IPC) were performed in the accident airplane on October 7, 2017. Between November 17, 2012, and his last logged flight on June 1, 2018, he recorded about 4.0 hours of simulated instrument experience. He recorded three instrument approaches and 1.0 hour of actual instrument flight time in the 6 months before the accident. His previous logged actual instrument flight before June 1 occurred on November 27, 2017, for 1.0 hour in actual instrument conditions with no instrument approaches. His next previous instrument experience was on the same day as the IPC, also 1.0 hour actual instrument flight with no approaches.
The flight instructor who performed the pilot's last flight review and IPC stated that the flight review lasted about 1.8 hours and the IPC about 1.7 hours. Both flights and about 8.0 hours of ground instruction were conducted through Bonanza/Baron Pilot Training Inc. The instructor stated that the pilot executed eight instrument approaches and holding procedures but did not perform "partial panel" or procedures for loss of primary flight instruments, contrary to IPC guidance. The instructor described the pilot as competent. The pilot's relatives reported he was in excellent health and exercised daily, and that he was a "by the book" pilot.
Aircraft Information
The airplane was equipped with a Bendix/King KFC-200 three-axis autopilot flight control system, including an autopilot annunciator panel. After the accident, the annunciator panel was examined at the NTSB Materials Laboratory, which revealed that only the bulb filament for HDG (heading) was stretched. The static system provided static air for the rate-of-climb indicator, altimeter, and airspeed indicator from two static ports on the aft fuselage. An emergency static air valve was designed to provide cockpit static air and drain the plumbing as part of the preflight inspection. Maintenance records showed that a transponder test and altimeter, pitot-static, and altitude system checks were last performed on August 16, 2016.
The most recent annual inspection was completed on February 3, 2018, at an airplane total time of 2,044.1 hours. Engines and propellers were inspected on that date per a 100-hour inspection. Both engines and propellers had accrued 392.1 hours and 731.7 hours since major overhaul, respectively. The last maintenance entry dated June 1, 2018, recorded the hour meter at 2,059.0 hours. The aircraft was equipped with a Garmin GNS-530W GPS unit, but a portion would not power up, so no data were recovered. The airplane was fueled on June 12, 2018 at VAY with 36.0 gallons of 100 low lead fuel, filling the tanks to the tabs, which would have resulted in 166 gallons of usable fuel.
Meteorological Information
The pilot obtained an Outlook Briefing from ForeFlight.com at 1745 the night before the accident and filed an IFR flight plan. The briefing indicated no adverse weather advisories and clear skies with visual meteorological conditions from New Jersey to Hyannis. The Terminal Aerodrome Forecast for PNE expected marginal visual flight rules conditions with an overcast ceiling at 1,200 ft above ground level during the morning. No other weather briefing records were found. The National Weather Service Surface Analysis Chart for 0800 on the accident day depicted a low-pressure system over Canada with an occluded frontal system; a warm front extended east-southeast across New York into northern New Jersey. The accident site was south of the warm front in the warm air sector. Weather depiction charts showed IFR conditions due to low ceilings and visibility restricted in fog or mist.
A weather observation from VAY at 0854 reported calm wind, visibility 2 1/2 miles in mist, overcast ceiling at 500 ft agl, temperature and dew point each 19°C, and altimeter 30.00 inches of mercury. Cloud bases were at 378 ft agl with saturated conditions to 6,000 ft and clouds above 10,000 ft. The sounding indicated a stable atmosphere supportive of nimbostratus clouds producing drizzle or light rain and fog. The Terminal Aerodrome Forecast for WRI issued at 0600 forecast wind from 200° at 9 knots, visibility about 5 miles in light rain showers, overcast clouds at 1,500 ft agl. The only advisory applicable was AIRMET Sierra for IFR conditions, issued at 0741, expecting ceilings below 1,000 ft and visibility less than 3 statute miles with mist, conditions ending between 0800 and 1100.
Wreckage and Impact Information
The initial impact occurred in a field about 6.5 nautical miles and 040° from the approximate center of runway 08/26 at VAY. Ground scars and wreckage were noted on both sides of an adjacent road. The initial impact point was a depression with a green glass lens embedded in the ground. A ground scar oriented on a magnetic heading of 055° was continuous from the wingtip for 70 ft. Aerial imagery indicated the estimated right bank angle at impact was about 30°. Based on the distance between the wingtip and right engine (13 ft) and the measured distance between their ground scars (33 ft), the descent angle was estimated at about 20°.
The outboard portion of the right stabilizer was in the ground scar. Pieces of battery box and VHF antenna were along the scar. The left propeller, with two attached blades, was partially buried. Also along the scar were the pitot tube, pieces of carpeting, cabin roof, and pieces of fuel bladder tank with access panel. The right propeller, with all three blades attached, was past the end of the scar, and a single left propeller blade was found near it. Debris was strewn across the road, but no scrape marks were found on the road. Fuel blight was noted in the field and among tree leaves.
The cockpit, cabin, and wings were heavily fragmented; both wing spars were fractured at the wing roots. No preimpact failure or malfunction of structural components was evident. Both engines separated and both propellers separated from the engines. No pre- or postimpact fire was observed. All primary and secondary flight control surfaces for pitch and yaw remained attached or were recovered; a portion of the roll control hinge was found. Elevator and aileron primary flight control cables from the cockpit were not located. Examination of remaining cables showed no preimpact failure. Both flap actuators were in the flaps-retracted position; the landing gear gearbox indicated the gear was retracted.
Examination of the static system: left static port was clear and the Poly-flo tube was attached. The right static port had dirt in one of three holes; the Poly-flo tube was separated from the port but had a clamp. The "T" fitting had all tubes connected. No identifiable Poly-flo tube forward of FS 170 was found. The emergency static source valve was not located. The throttle quadrant was separated; left throttle full aft, right throttle 1/4 forward from full aft. Propeller controls were full forward, mixture controls mid-travel or forward. Elevator trim was 13 units airplane nose-up. Secondary flight control actuators: left and right elevator extended 1.2 inches (10° trailing edge down), rudder extended 4.1 inches (5° trailing edge left), aileron extended 1.2 inches (7° trailing edge up).
The autopilot computer was recovered from the nose compartment. Yaw, pitch, and pitch trim servos remained secured; bridle cables were around capstans; roll servo capstan was impact damaged. Electrical connections were secured. Components were sent to the manufacturer for examination with FAA oversight. No bird remains were found on windscreen pieces. Examination of the pilot's attitude indicator rotor housing showed 270° circumferential scoring but no obvious impact impressions. Another attitude indicator showed slight scoring of the rotor housing. Both engines showed no preimpact failure. The left engine-driven vacuum pump was separated and not recovered; the right engine-driven vacuum pump showed no preimpact failure. Propeller blades exhibited twisting toward low pitch, bending, and gouging, consistent with impact.
Additional Information
14 CFR Part 61.57(c) requires that a pilot acting as pilot-in-command under IFR or in weather below VFR minimums must have performed and logged at least six instrument approaches, holding procedures, and intercepting/tracking courses within the preceding six calendar months. Failure to meet this requirement for more than six months requires an instrument proficiency check. According to paperwork from Angel Flight East, the patient appointment was scheduled for the afternoon of June 14, and comments indicated the flight could take place after 12 noon on June 13 or the morning of June 14. The FAA Instrument Flying Handbook notes that a static system blockage can cause the altimeter to "freeze" at the altitude where blockage occurred. ADS-B reports two types of information; the specific details are provided in the FAA's frequently asked questions.
Probable Cause
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