History of Flight
On February 16, 2022, about 1707 eastern standard time, a Beech 58 airplane, N58LF, was destroyed in an accident near Lexington, North Carolina. The private pilot was fatally injured; the driver and passenger of an impacted tractor-trailer sustained minor injuries. The flight was conducted under 14 CFR Part 91 as a personal flight.
The pilot arrived at Davidson County Airport (EXX) that afternoon to pick up his airplane after an annual inspection. Witnesses observed him performing engine runs at varied rpms before departure, then an aborted initial takeoff attempt, followed by a taxi back to the maintenance facility for corrective action due to a reported door latch issue. He then returned to the runway to initiate takeoff.
Three witnesses on the airport ramp observed part of the takeoff roll, rotation, and initial climb before losing sight of the airplane just before impact. One witness reported seeing smoke trailing the right engine when the airplane rotated. Airport security video captured white smoke trailing the airplane at rotation and continuing until the airplane went out of camera view, about halfway down the runway. A second witness, also a pilot, reported that the right engine was spewing dense white smoke that the video did not accurately depict. Witnesses noted the airplane leveled off or decreased its nose-up pitch attitude; one reported hearing engine gyrations associated with one engine losing power or engines being out of sync. A photograph taken when the airplane was about 2,664 ft down the 5,004-ft-long runway showed the airplane in a climb attitude with landing gear extended and smoke trailing the right engine. As the airplane continued, the landing gear retracted and about that time the right engine lost power and its propeller stopped rotating. When the airplane was at the departure end of the runway, either white or white/blue smoke was noted trailing the left engine, and the airplane was described as not having power. It banked left, stalled, and pitched nose down before disappearing behind terrain.
Another witness, located about 1/4 mile north of the accident site, observed the airplane departing and an “engine wasn’t turning.” He saw the airplane descend, heard a loud sound, then saw smoke.
The airplane subsequently impacted a tractor-trailer. The driver reported traveling at 65 mph at the time of collision. After the tractor-trailer turned over and came to rest, the driver and passenger evacuated the cab.
A video recording from a tractor-trailer behind the impacted truck showed the airplane in a very slight nose-up attitude before impact. Although the impact was not recorded, the video showed the tractor-trailer rolling onto its side and an eruption of flames.
Aircraft Information
The airplane was equipped with two 285-horsepower engines (at 2,700 rpm) with two-blade, constant speed, manually feathering, single-acting propellers. It also had a graphic engine monitor, but data was not available due to extensive heat damage.
According to maintenance records, while inbound to EXX in October 2021 for an annual inspection, the No. 1 cylinder of the right engine exhibited excessively high cylinder head temperature (CHT) and exhaust gas temperature (EGT) readings. Witnesses reported seeing the accident pilot land uneventfully with the right propeller feathered and the right engine secured.
The pilot later reported on an internet forum that during cruise flight to the maintenance facility, he suddenly noted the No. 1 CHT of the right engine was 540°F, 80°F above the maximum continuous CHT limit. He reduced throttle and mixture control, then pushed them in before noting EGT increase for five cylinders but not the No. 1 cylinder. He then feathered the right propeller and continued.
During the annual inspection, maintenance personnel identified no compression in the No. 1 cylinder of the right engine. Borescope inspection revealed damage to the cylinder walls and extensive piston damage. Repair station personnel attributed the damage to detonation caused by pilot-reported excessive leaning. No troubleshooting was done to determine the root cause, and no engine monitor data was downloaded for that event.
Repairs to the right engine included removing internal contamination; cleaning, flushing, and inspecting components; installing a serviceable cylinder and connecting rod; and installing a piston with untraceable origin. Damaged parts were scrapped and unavailable for investigation. New fuel injector nozzles were installed per STC SE09217SC. After repairs, the engine was test run with the cowling off for leaks, then run with cowling on for 20–30 minutes, sometimes at full power, with no discrepancies noted. The right engine oil filter was cut open after extended ground runs; records reflected “only trace amounts of metal found. Will check again after test flight. After engine run, cut open filter to inspect, found no defects at this time. Installed new filter.” The airplane was not test flown after the annual inspection, nor was it required to be. No discrepancies were reported for the right engine baffling. The maintenance facility did not download engine monitor data post-maintenance.
The airframe and powerplant mechanic with inspection authorization who performed most of the annual inspection refused to return the airplane to service, believing the engine should have been removed and sent out. Another mechanic with the facility researched the engine manufacturer’s maintenance manual section on foreign object contamination and returned the airplane to service after removing all internal contamination to his satisfaction.
The EXX airport manager reported no record of the pilot purchasing fuel since arriving in mid-October.
The airplane’s Pilot’s Operating Handbook specified takeoff mixture full rich unless leaned for field elevation.
Wreckage and Impact Information
Examination of the accident site revealed the airplane impacted on grass immediately adjacent to a three-lane highway. Marks in grass adjacent to the highway were oriented on a southerly heading and nearly perpendicular to the highway. The site was slightly less than 2,000 ft south-southwest of the departure end of runway 24.
The cockpit and cabin were upright about 394 ft south-southwest from the initial ground impact location. The impacted tractor-trailer was resting on its left side immediately adjacent to the cockpit, cabin, and separated aft empennage. Extensive thermal damage from postimpact fire was noted to the cockpit and cabin. No evidence of in-flight fire in either engine compartment.
Flight control examination revealed no preimpact failure or malfunction of primary or secondary controls. Flap actuators indicated flaps retracted. Elevator trim tab actuators indicated 15° and 27° tab trailing edge down (nose-up) for left and right respectively. Rudder trim tab actuator indicated 25° tab trailing edge left (nose right), maximum value. Aileron trim tab actuator indicated 2° tab trailing edge up. Landing gear doors were closed and gear was retracted.
Fuel selectors for left and right engines were positioned to left and right fuel tanks respectively. No preimpact failure or malfunction of the airframe fuel supply and vent systems, though thermal damage consumed some hoses and lines. Fuel boost pumps were not tested due to heat damage.
The left engine separated during impact and sustained impact and heat damage. Crankshaft, camshaft, and valvetrain continuity was confirmed. Thumb suction and compression were confirmed for each cylinder. No preimpact failure or malfunction was noted in air induction, exhaust, ignition, or lubricating systems. The No. 3 fuel injector nozzle was not installed in its cylinder but remained attached to its line; all threads of the separated nozzle were sooted. Other nozzles were properly installed. Metallurgical examination of the No. 3 nozzle threads showed no evidence of shearing or stripping.
The right engine separated during impact. Crankshaft, camshaft, and valvetrain continuity and thumb suction/compression were confirmed. No preimpact failure or malfunction of exhaust or lubricating systems. After removing the No. 1 cylinder, damage was noted to the aft side of the piston near the chamfered edge. The No. 5 cylinder had white residue near the fuel injector nozzle port. Fourier transform infrared spectroscopy of the residue was consistent with carboxyamine or a mixture of amines and carboxylic acids, common additives in aviation gasoline. The No. 1 cylinder’s piston had minor erosion at bevel edges and minor longitudinal scoring on the skirt; combustion chamber inner top and exhaust valve had a minor grit blast-like appearance.
Examination of the right engine ignition system revealed both magnetos were impact-separated; ignition leads had extensive impact damage. No. 1 cylinder spark plugs exhibited black color and normal wear; postaccident testing at 80 psi produced a strong blue spark with no evidence of preimpact failure.
No preimpact failure or malfunction was noted in the right engine exhaust, lubricating system, or manifold valve. Heat damage to the metering valve precluded operational testing without replacement of internal parts; testing was not performed. Non-ferrous particles were noted in the oil pump housing. Disassembly inspection of the engine-driven fuel pump (impact-separated) revealed no evidence of preimpact mechanical failure. Operational testing after replacing impact-damaged components (without changing adjustment) showed pump discharge pressure of 15.69 psi, about 47% greater than the maximum specified limit at 2,600 pump rpm.
The left propeller blades were bent forward in the thrust direction, consistent with developing power at impact. Disassembly showed impact marks at blade angles of 29°, 16°, and 14° in the low pitch range. No evidence of preimpact failure or malfunction. The left propeller governor had heat damage but control arm moved; operational testing not performed, no evidence of preimpact failure.
The right propeller blades were near the feather position; internal pitch change mechanism intact. One blade had chordwise static scoring at the tip; the other had slight aft bending, consistent with not developing power at impact. No evidence of preimpact failure or malfunction. The right propeller governor rotated freely; screen clean; non-ferrous particles flowed from oil during hand rotation. Control head position not documented due to separation. No evidence of preimpact failure.
Medical and Pathological Information
An autopsy of the pilot performed by the North Carolina Office of the Chief Medical Examiner determined the cause of death as blunt force injuries and the manner as accident. Other findings included moderate atherosclerosis in his left anterior descending coronary artery.