Fatal Beech 35-C33 Accident Near Pulaski, Tennessee (N5891J)

Accident Overview and Flight History On December 7, 2023, at 1103 central standard time, a Beech 35-C33 airplane, registration N5891J, was destroyed in an accident near Pulaski, Tennessee. The private pilot and one passenger sustained fatal injuries. The flight was a personal operation under Title 14 Code of Federal Regulations Part 91, originating from Knoxville Downtown Island Airport (DKX) at approximately 0948 and en route to Saline County Regional Airport (SUZ) in Benton, Arkansas, a distance of about 430 nautical miles. FAA air traffic control communications and ADS-B data indicated that the aircraft initially climbed and turned to a ground track of 255°, leveling off at 2,500 feet mean sea level (msl) for about 12 minutes before climbing to 6,500 feet msl. Communications during the departure and initial enroute phase were normal. As the flight progressed, the aircraft exhibited significant altitude and speed fluctuations. After 1020, the airplane began a series of descents to 6,000 feet with associated increases in groundspeed, followed by climbs back to 6,500 feet while slowing. An aircraft performance study using ADS-B data and the Beechcraft Debonair 35-C33 and Bonanza E33 F33 Pilot’s Operating Handbook indicated that by 1033, these fluctuations became more pronounced. The aircraft repeatedly gained and lost 1,000 to 1,500 feet of altitude while airspeed fluctuated between 100 and 160 knots. The rate of climb varied between -1,200 feet per minute during descents and near 500 feet per minute during climbs. Around 1036, the aircraft entered a descent arrested at approximately 5,300 feet at an airspeed of 133 knots, then climbed to its highest altitude of about 7,000 feet msl before descending again. The controller noted the pilot was “well left of course,” and the pilot acknowledged and stated she was correcting, though flight track data showed she remained significantly off course. After 1059, the aircraft slowed from 160 to 140 knots while level at about 4,500 feet before beginning a climb to above 6,000 feet, during which it continued to slow. The controller attempted to contact the pilot twice to advise her to contact Memphis center control, but received no response. At approximately 1103, a faint communication was received from the pilot stating, “…this is Debonair, [unintelligible…] Emergency.” This transmission coincided with a left turn, a descent rate of about 2,000 feet per minute, and an airspeed increasing to over 170 knots. About 60 seconds later, a faint male voice transmitted, “[unintelligible], oh…. help us.” Subsequent controller attempts to contact the pilot were unanswered. The aircraft was in a rapid descent before radar contact was lost near the accident site. In the final seconds, the airplane was on a ground track of 262°, descending at an airspeed of 230 knots with a descent rate exceeding 10,000 feet per minute. ## Personnel and Training Background The pilot, a 44-year-old private pilot, passed her Private Pilot Airplane Airmen Knowledge Test on October 20, 2021, and her private pilot (single-engine land) practical test on May 14, 2022, with 193.2 total flight hours. Of those hours, 182.6 were dual instruction, nearly all in a Piper PA-28-140 purchased on June 15, 2021. She sold that aircraft and purchased the accident airplane on July 13, 2022. Her logbook, found heavily damaged at the accident site, showed 390.3 total hours as of August 14, 2023. A former flight instructor stated that the pilot “leaned on technology too much and did not have solid stick and rudder flying skills,” often confusing trim direction and manually adjusting it incorrectly. The instructor noted that if the trim was in the wrong position or the autopilot was not functioning properly, the pilot would disconnect it and fly manually, often pressing the autopilot’s Up or Down buttons repeatedly rather than gently holding them. The general manager of the pilot’s flight school reported that her training progress was not meeting necessary proficiency levels. Several weeks before the accident, she was given an instrument phase check that did not go well in almost all aspects of aircraft control, situational awareness, and risk management. The manager advised her that she was behind in the Debonair and believed she had purchased more aircraft than she was ready for. The pilot and her father did not disagree with this assessment. ## Aircraft and Systems The accident airplane was equipped with a Continental IO-470-N six-cylinder, fuel-injected engine producing 260 horsepower, retractable landing gear, and a constant-speed propeller, making it a complex and high-performance aircraft. It had a maximum structural cruising speed of 161 knots and a never-exceed speed of 195 knots. The aircraft was equipped with a Century 2000 autopilot, a prompting system that did not include automatic elevator trim control. When the autopilot displayed a flashing TRIM UP or TRIM DOWN annunciator, the pilot was required to manually move the trim control in the indicated direction. The trim lamp would extinguish when the autopilot determined the trim condition was satisfied. Small trim errors caused the prompt to flash approximately once per second, while large errors caused it to flash approximately three times per second. A large error uncorrected for about two minutes would trigger a five-second alert, repeating every two minutes until corrected. The pilot’s previous aircraft, a Piper PA-28-140, had fixed landing gear, a fixed-pitch propeller, and a 160-horsepower engine, and was not a high-performance or complex airplane. It was equipped with a Bendix King/Tru Trac autopilot, with a cruise speed of about 110 knots and a maximum speed of 125 knots. ## Wreckage and Impact The airplane impacted hilly, wooded terrain at an elevation of 971 feet, with the wreckage path oriented on a heading of about 268° magnetic. The wreckage was highly fragmented, with a debris field extending in a fan-like pattern about 100 yards long. Tree tops leading to the main wreckage were cut off at progressively lower heights. Fuel tanks were breached by impact, and a post-impact fire spread to surrounding trees and undergrowth. A witness reported the airplane flew overhead at high speed and that the engine was running at impact. All major components were located at the site. The engine was partially buried in a crater 5 feet deep by 8 feet wide and severely damaged; crankshaft continuity and cylinder compression could not be confirmed. The magneto key was broken off in the switch and set to the “Both” position. Both magnetos separated from the engine and could not be functionally tested. Spark plugs showed impact damage but minimal wear and no evidence of carbon or lead fouling. Propeller blades separated from the hub during impact; one was buried in the crater with significant bending and chordwise scraping, while the opposing blade was found 30 feet west with slight bending and chordwise scraping. The propeller spinner exhibited rotational crushing damage. Flight control system components were significantly damaged or destroyed by impact and fire, and continuity could not be established. All observed breaks in flight control cables displayed features indicative of tensile overload, with “broomstraw” appearances consistent with impact-related separation. The elevator trim actuator measurement correlated to a 5° deflection of the left trim tab in the trailing edge down direction; the right trim tab position could not be determined. The rudder, left horizontal stabilizer, and elevator remained attached to the empennage and were free to move when manually manipulated. The rudder cables remained attached to the bellcrank, and elevator cables remained attached to a fractured bellcrank. One flap actuator was found loose but could not be attributed to a specific side. The cockpit was destroyed by impact and fire, and no flight instrumentation or gauges could be accurately identified or read. The autopilot’s instrument panel faceplate was identified, but no settings could be determined, and the autopilot servos were damaged. Two video recording devices were found in the wreckage. Both appeared intact with superficial exterior damage and retained their micro-SD data cards. Examination revealed that the memory card from one device was destroyed beyond repair, and the other did not contain any video recordings, with forensic examination recovering only deleted files from previous flights, indicating the camera was likely not recording during the accident. ## Medical and Toxicological Findings The pilot’s last aviation medical examination was on January 20, 2023, at which time she reported using fexofenadine, an over-the-counter, non-sedating antihistamine. She reported no other active medical conditions and was issued a third-class medical certificate with a limitation requiring corrective lenses. The Middle Tennessee Regional Forensic Center performed the pilot’s autopsy for the Giles County Medical Examiner, determining the cause of death as multiple injuries and the manner of death as accident. Due to the extent of injuries, the autopsy was limited for evaluation of natural disease. Toxicological testing by NMS Labs and the FAA Forensic Sciences Laboratory detected multiple substances in postmortem liver and muscle tissue. Alprazolam was detected at 530 ng/g in liver tissue by NMS Labs and 222 ng/g by the FAA, with alpha-hydroxyalprazolam detected at 56 ng/g and 57 ng/g, respectively. Alprazolam was also detected in muscle tissue at 81 ng/g by the FAA. Trazodone was detected in liver tissue at 286 ng/g and muscle tissue at 56 ng/g. Buspirone was detected in liver tissue at 55.5 ng/g and muscle tissue at 3.8 ng/g. Ondansetron, propranolol, fexofenadine, and azacyclonol were detected in both liver and muscle tissue. Oxymetazoline was detected in liver tissue but not in muscle tissue. Alprazolam is a potent prescription benzodiazepine used to treat anxiety and panic disorders, carrying warnings for central nervous system depression, increased sedation, reduced concentration, and reduced inhibitions. The FAA classifies alprazolam as a Do Not Issue/Do Not Fly medication. Trazodone is a prescription antidepressant that may slow thinking and impair motor skills, and is also classified as Do Not Issue/Do Not Fly by the FAA. Buspirone, used to treat anxiety, may cause dizziness and is classified as Do Not Fly. Ondansetron, used for nausea and vomiting, is disqualifying for FAA medical certification due to side effects including serious heart rhythm irregularities, drowsiness, and dizziness. Propranolol, used for various conditions including anxiety, has minimal cognitive effects and requires case-by-case FAA evaluation. Fexofenadine and oxymetazoline are not generally considered impairing.