N36VERaytheon Aircraft 58 · 2000

On January 11, 2013, about 1553 central standard time, N36VE, a Raytheon Aircraft Company 58, multi-engine airplane, was destroyed after impacting terrain near Maxwell, Nebraska. The pilot and three passengers were fatally injured. The airplane was registered to and operated by Bottorff Construction, Inc.; Atchison, Kansas. Instrument meteorological conditions (IMC) prevailed at the time of the accident and an instrument flight rules (IFR) flight plan had been filed for the 14 Code of Federal Regulations Part 91 business flight. The airplane departed North Platte Regional Airport (LBF), North Platte, Nebraska, about 1545, and was en route to York Municipal Airport (JYR), York, Nebraska.

About 1550 the pilot reported to a radar controller at Denver Air Route Traffic Control Center that he was climbing to a planned cruise altitude of 9,000 feet mean sea level (msl) . At 1552 the pilot requested the tops of the clouds; however, a current report on the cloud tops was not available. At 1553 a "mayday" call was heard and a simultaneous loss of radio and radar contact was reported by the radar controller.

At 1855 the wreckage was found in a remote area about 11 miles north east of LBF by emergency responders who had been searching for the missing airplane.

The pilot, age 54, held a Federal Aviation Administration (FAA) private pilot certificate with ratings for airplane single engine and multiengine land, and instrument airplane. His private pilot certificate in airplane single engine land was initially issued on March 9, 1988, his rating in instrument airplane was issued on March 20, 2002, and his rating in airplane multiengine land was issued on February 25, 2003.

The pilot also held an FAA third-class medical certificate, issued on August 15, 2012, with a restriction "must have available glasses for near vision".

A review of portions of the pilot's three logbooks showed entries beginning on February 17, 1986, with the last entry in pilot's logbook number three on January 1, 2013. Based on only the incomplete entries in pilot's logbook number three, his total pilot experience was estimated at 1,377 hours, with about 457 hours in multi-engine airplanes, and the remainder in single-engine airplanes. His instrument flying experience was estimated at 171 hours. Logbook entries for the previous calendar year showed he had flown about 103 total hours, of which about 80 hours were in the accident airplane.

A pilot logbook endorsement on December 6, 2011, showed he had completed an instrument proficiency check and a course in BE 58P Differences, including 4 hours of simulator flight training and 2.5 hours of classroom training. The most recent instruction from a certified flight instructor was on February 20, 2012, showing a flight review was completed in a Beechcraft 58P airplane which included 2.0 hours of flight instruction and 0.5 hours of actual instrument flying.

The low-wing, retractable conventional landing gear, multi-engine airplane, serial number (s/n) TH-1957, was manufactured in 2000. It was powered by two 285-horsepower Continental Motors, Inc. engines; s/n 1005940 installed on the left side, and s/n 1005978 installed on the right side. Each engine drove a Hartzell model PHC-J3YF-2UF, 3-blade metal alloy full feathering propeller.

The airplane was equipped with ice protection systems which included a surface deice system, electrothermal propeller deice, pitot heat, stall warning anti-ice, and heated fuel vents.

A postaccident review of original aircraft maintenance documents provided by the operator showed that an annual inspection was completed on May 21, 2012, at an airplane total time and Hobbs meter time of 1,740.9 hours. Entries also noted that both engines were installed on that date and were factory new "zero time" engines.

The last aircraft maintenance logbook entry on December 7, 2012, showed that the aircraft total time and Hobbs meter time was then 1,835.0 hours.

Fuel records at LBF showed that the pilot had the main fuel tanks "topped off" with a total of 80.0 gallons of 100LL aviation gasoline and the credit card fuel slip was time-stamped at 1443.

At 1534 the Automated Surface Observation System at LBF reported wind from 350 degrees at 14 knots, visibility 4 miles in mist, ceiling overcast at 1,000 feet above ground level (agl), temperature minus 2 degrees Celsius (C), dew point minus 4 degrees C, altimeter 29.42 inches of mercury. Remarks included: ceiling 700 variable 1,300 feet agl.

At 1553 LBF reported wind from 340 degrees at 14 knots gusting to 20 knots, visibility 3 miles in light freezing rain and mist, ceiling broken at 900 feet agl, overcast clouds at 1,200 feet, temperature minus 2 degrees Celsius (C), dew point minus 4 degrees C, altimeter 29.45 inches of mercury. Remarks included: freezing rain began at 1546, ceiling 600 variable 1,100 feet agl, pressure rising rapidly, hourly precipitation less than 0.01 inch.

The National Weather Service Aviation Weather Centers (AWC) Area Forecast issued at 1425 expected overcast clouds at 5,000 feet mean sea level (msl) with tops to 16,000 feet msl with visibility 3 miles in mist over southern Nebraska. The forecast was amended by AIRMET Sierra for IFR conditions over the region, which forecasted ceilings below 1,000 feet and visibility below 3 miles in precipitation, mist, and blowing snow, over all of Nebraska. AIRMET Zulu was issued at 1445 which called for moderate icing conditions below 17,000 feet msl.

The pilot had contacted the FAA contract Automated Flight Service Station (AFSS) several times during the day for each of his flights. On the last call at 1452 the pilot was advised of the AIRMET for icing conditions and turbulence below 8,000 feet, and the pilot made a comment that he was expecting those conditions to be developing over the area. At that time a SIGMET or a Center Weather Advisory warning of severe icing conditions had not been issued.

Two helicopter flight crews operating into LBF immediately after the accident reported they had not anticipated the lower than forecast weather conditions and the wintery mix they encountered. The first flight crew was operating a group of U.S. Army Blackhawk helicopters that landed at LBF about a half hour after the accident. They encountered lowering ceilings less than 500 feet with light freezing rain and mist which changed to a combination of freezing rain, ice pellets, and snow with increasing winds. When the next flight of four Blackhawk helicopters landed a short time later they encountered blowing snow with low visibility.

Statements from the crew of a U.S. Army King Air indicated they were inbound to LBF and observed a weather cell north and west of the area moving eastward on their airborne weather radar. Upon descending below 11,000 feet they entered the clouds and encountered icing at approximately 9,000 feet. The icing became heavy to severe icing at 5,000 feet. After they received a field condition report of braking action nil on the runway at LBF they executed a missed approach and diverted to an alternate airport. After landing at the alternate airport, the flying pilot commented on a large area of residual ice that remained in an unprotected area on the airplane.

A multi-engine instrument rated pilot who was in a duck blind immediately northwest of the airport witnessed the accident airplane on climb-out after takeoff from runway 30. He reported mist conditions and fog that was "freezing to surfaces". He was also indicated that surface conditions deteriorated shortly afterward with visibility as low as a quarter mile when it began to "snow hard".

At 1448:32 the pilot of N36VE called the Fort Worth Federal Contract Flight Service Station (FCFSS) via telephone to file two IFR flight plans. He obtained an abbreviated pilot weather briefing for a flight from LBF to JTY, and a second proposed IFR flight from JTY to St. Joseph, Missouri. The pilot's telephone conversation with the FCFSS ended at 1454:14.

Following is a timeline of selected communications between the pilot of N36VE and Federal Aviation Administration (FAA) Air Traffic Control (ATC). A summary of the FAA ATC radar contacts is included.

1544 N36VE reported to ATC that he was on the ground at LBF and ready for departure

1545 ATC cleared N36VE to JYR "as filed" with instructions to climb and maintain 9,000 feet

1547:03 Radar showed N36VE was at a transponder reported altitude of 3,000 feet

1548:57 N36VE reported to ATC that he was at 4,700 feet and climbing to 9,000 feet

1550:35 Radar showed N36VE was at a transponder reported altitude of 6,100 feet

1552:30 Radar showed N36VE was at a transponder reported altitude of 6,900 feet

1552:35 N36VE asked ATC if they had any reports on the tops of the clouds

1552:39 ATC responded that they did not

1552:39 Radar showed N36VE was at a transponder reported altitude of 7,000 feet

1552:58 Radar showed N36VE was at a transponder reported altitude of 7,100 feet

1553:08 Radar showed N36VE was at a transponder reported altitude of 6,600 feet

1553:15 N36VE (voice identified as the pilot) said "mayday mayday mayday three six …" (there was a change in the sense of urgency noted in the voice of the pilot and the end of the transmission was cut off)

No further communications from N36VE were received

1553:18 Radar showed N36VE was at a transponder reported altitude of 3,800 feet

Radar contact was then lost.

The wreckage was located in remote ranch land about 11 miles northeast from LBF and about 8 miles north from Maxwell, Nebraska. The wreckage was extensively fragmented and included evidence of a postimpact fire. The wreckage was spread out over sandy soil in hilly terrain that was covered with grass and snow. The elevation of the initial impact crater was estimated as 2,925 feet msl.

The debris path was oriented from southwest to northeast on a magnetic bearing of 057 degrees. The debris path was about 417 feet long and about 215 wide at the widest points. The initial impact scars were created by the left wing, left engine, the lower nose section of the airplane, and the right engine.

The initial impact crater was a large ground scar which measured 25 feet long and 2 feet 4 inches at its deepest point. The west side of the ground scar was 10 feet wide and the east side of the ground scar was 7 feet 5 inches at its widest point. This ground scar contained the left engine propeller assembly, torn fragmented and accordion crushed metal, a propeller blade from the right engine, and the nose gear assembly. Two of the propeller blades from the left engine and one propeller blade from the right engine were imbedded in the ground. Dirt in the ground scar was ejected to the northeast.

A second ground scar branched off from the west side of the large ground scar. The second scar measured 17 feet long, 2 feet 5 inches at its widest point, and 9 inches at its widest point. The ground immediately adjacent the large ground scar exhibited exposure to heat and fire. The burned area extended for 120 feet towards the north and was 62 feet at its widest point. The empennage, both engines, the right propeller assembly, fragmented portions of the left wing and fuselage, and some personal effects were all located within the burn area.

The left wing was fragmented into several large pieces and included the left aileron, left flap, and left main landing gear assembly. These pieces were located in the burn area to the north of the empennage. The left main landing gear was charred, melted, and partially consumed by fire. The left aileron and left flap exhibited exposure to heat and fire. Both the aileron and flap were bent and wrinkled.

The empennage included the horizontal and vertical stabilizer, the left and right elevator, and the rudder. The left horizontal stabilizer de-ice boot was burned and torn. The elevator was bent and charred, and partially melted or consumed by fire. The left stabilizer was bent and torn and exhibited exposure to heat and fire. The vertical stabilizer was crushed aft and the de-ice boots were torn. The rudder exhibited exposure to heat and fire. The right horizontal stabilizer de-ice boot was burned. The leading edge exhibited aft accordion crushing and both the stabilizer and the elevator exhibited exposure to heat and fire.

The right wing was fragmented into several large pieces and included the right aileron, right flap, and right main landing gear assembly. These pieces were located to the east of the burn area. The right main landing gear separated from the wing assembly and was otherwise unremarkable. The right aileron and right flap were bent and wrinkled.

The fuselage was fragmented and the pieces were located within the debris field. A large portion of the forward fuselage was found at the north end of the debris field, 60 feet north of the end of the burned field. The forward portion of the fuselage included upper and lower skin from the forward fuselage, portions of the flight control cables, the fragmented instrument panel, and wiring harnesses.

The airplane fuel system was fragmented and scattered among the debris path. Both fuel selector valves, located in each main landing gear wheel well, were separated from the airplane and from their cable controlled fuel selector valve handles, located in the cockpit. The left fuel selector valve handle was found at the approximate 10:00 position. The right fuel selector valve handle was found at the approximate 12:00 position (12:00 position being forward and ON position). Four fuel tank caps were observed in the debris path. The cabin seats, seatbelts, personal effects, and the remainder of the airplane were highly fragmented and scattered to the north and east from the main ground scar, both inside and outside of the burn area.

The on-scene examination of the wreckage revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation.

An autopsy was performed on the pilot by the Nebraska Institute of Forensic Sciences, Inc.; Lincoln, Nebraska.

Forensic toxicology was performed on specimens from the pilot by the FAA, Aeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated that tests for Carbon Monoxide and for Cyanide were not performed. The report also stated that Ethanol was not detected in Muscle or in Liver, and that no Drugs were detected in Liver.

The wreckage was moved to another location and examined.

Left Engine

The left engine was separated from the airframe and located in the burned area of the debris field and exhibited impact and thermal damage. The crankcase was fractured in several places and the accessory section was fractured and portions were not observed. Both magnetos were separated from the engine and severely fragmented. The spark plugs were removed and exhibited normal signatures when compared to the Champion Check A Plug Chart. The electrodes exhibited dark grey combustion deposits.

The separated throttle body / metering unit was examined. The fuel pump, fuel screen, fuel manifold valve, and fuel nozzles were examined. The oil pump was disassembled and examined. The cylinders remained attached to the crankcase and exhibited impact damage. Portions of the number 6 cylinder head were separated and not observed. The combustion chambers were examined with a lighted bore scope. All of the valve covers were fragmented and breached and the overhead areas of the cylinders contained dirt and debris.

The left propeller was separated from the engine, and the crankshaft propeller flange remained attached to the propeller hub. Examination of the engine crankshaft propeller flange separations revealed that it exhibited signatures consistent with torsional overload. One of the three propeller blades was fractured free from the hub. All three blades exhibited various bends, polishing, and multi-directional scratches.

The left vacuum pump was separated from the engine and exhibited impact damage. It was disassembled and the vanes were intact. The rotor was impact fragmented and the vacuum pump housing was unremarkable.

Right Engine

The right engine was separated from the airframe and located in the burned area of the debris field and exhibited impact and thermal damage. The crankcase was fractured and portions of the accessory section were not observed. The right crankshaft propeller flange was separated and remained attached to the propeller. Both magnetos were separated from the engine and fractured into several pieces. The spark plugs were removed and exhibited normal signatures when compared to the Champion Check A Plug Chart. The electrodes exhibited dark colored combustion deposits.

The separated throttle body / metering unit was examined. The fuel pump was disassembled and examined. The fuel screen, fuel manifold valve, and fuel nozzles were examined. The oil pump was partially disassembled and examined. The cylinders remained attached to the crankcase and exhibited impact damage. Portions of the number 6 cylinder head were separated and not observed. The combustion chambers were examined with a lighted bore scope. All of the valve covers were fragmented and breached and the overhead areas of the cylinders contained dirt and debris.

The right propeller was separated from the engine, and the crankshaft propeller flange remained attached to the propeller hub. Examination of the engine crankshaft propeller flange separations revealed that it exhibited signatures consistent with torsional overload. One of the blades was fractured free of the hub. The blades exhibited scratches, nicks, polishing, and multidirectional bends.

The right vacuum pump was separated the engine and exhibited impact damage. It was disassembled and the vanes were intact. The rotor was impact fragmented and the vacuum pump housing was unremarkable.

The postaccident examination of the engines revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

Other Examination:

A Garmin GPSMAP 696 device was removed from the wreckage and was sent to the NTSB Vehicle Recorder Laboratory. An exterior examination revealed the unit had sustained catastrophic impact damage and the integrated circuit containing track log memory was ejected from the main printed circuit board and was not recovered.

No data was recovered from the Garmin GPSMAP 696.

According to the FAA Approved Airplane Flight Manual (AFM) for the Raytheon Aircraft Beech Baron 58, the Limitations section on page 2-12 showed that the minimum airspeed during icing conditions was 130 knots.

The AFM also noted additional limitations when encountering severe icing conditions:

"WARNING Severe icing may result from environmental conditions outside of those for which the airplane is certificated. Flight in the freezing rain, freezing drizzle, or mixed icing conditions (supercooled liquid water and ice crystals) may result in ice build-up on protected services exceeding the capability of the ice protection system, or may result in ice forming aft of the protected services. This ice may not be shed using the ice protection systems, and may seriously degrade the performance and controllability of the airplane.

1. During flight, severe icing conditions that exceed those for which the airplane is certificated shall be determined by the following visual cues. If one or more of these visual cues exist, immediately request priority handling from Air Traffic Control to facilitate a route or an altitude change to exit the icing conditions.

a. Unusually extensive ice accumulation on the airframe and windshield in areas not normally observed to collect ice.

b. Accumulation of ice on the upper surface of the wing, aft of the protected area.

c. Accumulation of ice on the engine nacelles and propeller spinners farther aft than normally observed.

2. Since the autopilot, when installed and operating, may mask tactile cues that indicate adverse changes in handling characteristics, use of the autopilot is prohibited when any of the visual cues specified above exist, or when unusual lateral trim requirements or autopilot trim warnings are encountered while the airplane is in icing conditions.

3. All wing icing inspection lights must be operative prior to flight into known or forecast icing conditions at night. [NOTE: This supersedes any relief provided by the Master Minimum Equipment List (MMEL).]"

According to the FAA Instrument Flying Handbook FAA-H-8083-15B; Chapter 10 on page 10-24: "The very nature of flight in instrument meteorological conditions (IMC) means operating in visible moisture such as clouds. At the right temperatures, this moisture can freeze on the aircraft, causing increased weight, degraded performance, and unpredictable aerodynamic characteristics. Understanding avoidance and early recognition followed by prompt action are the keys to avoiding this potentially hazardous situation … Structural icing is a condition that can only get worse. Therefore, during an inadvertent icing encounter, it is important the pilot act to prevent additional ice accumulation. Regardless of the level of anti-ice or deice protection offered by the aircraft, the first course of action should be to leave the area of visible moisture. This might mean descending to an altitude below the cloud bases, climbing to an altitude that is above the cloud tops, or turning to a different course. If this is not possible, then the pilot must move to an altitude where the temperature is above freezing. Pilots should report icing conditions to ATC and request new routing or altitude if icing will be a hazard."

According to the FAA "Aeronautical Information Manual"; section 8-1-5, Illusions Leading to Spatial Disorientation: "Various complex motions and forces and certain visual scenes encountered in flight can create illusions of motion and position. Spatial disorientation from these illusions can be prevented only by visual reference to reliable, fixed points on the ground

or to flight instruments ...A rapid acceleration … can create the illusion of being in a nose up attitude. The disoriented pilot will push the aircraft into a nose low, or dive attitude. A rapid deceleration by a quick reduction of the throttles can have the opposite effect, with the disoriented pilot pulling the aircraft into a nose up, or stall attitude .. An abrupt change from climb to straight and level flight can create the illusion of tumbling backwards. The disoriented pilot will push the aircraft abruptly into a nose low attitude, possibly intensifying this illusion".