N7345RBeech 95-B55 (T42A) · 1974

On January 14, 2024, at 1125 eastern standard time, a Beechcraft 95-B-55 twin-engine airplane, N7345R, was substantially damaged when it impacted terrain near Leyden, Massachusetts. The flight instructor, pilot receiving instruction, and a passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight.

A review of ADS-B data revealed that the airplane departed runway 20 at Westfield-Barnes Regional Airport (BAF), Westfield/Springfield, Massachusetts, about 1106. After departure, the airplane made a 180° left turn toward the north-northeast. The airplane then climbed to about 3,000 to 3,300 ft mean sea level (msl) and made four alternating left and right 360° turns while continuing to fly northbound. After the fourth 360° turn, the airplane began to climb to the north, reaching an altitude of about 4,000 ft msl. The airplane then entered a rapid descent until data ended at 1125:35. The location of the last recorded ADS-B data point was coincident with the accident site (see figure 1).

Figure 1. Plotted ADS-B data of entire flight (yellow line), including the departure airport (blue) and area of wreckage (orange).

The flight was not receiving any air traffic control services, and there were no recorded radio communications to or from the flight.

Several witnesses heard and/or observed the airplane. One eyewitness was walking his dog when he first heard the airplane’s engines and looked up. He said the airplane was “trying to gain altitude” and “then stopped” before the nose of the airplane dropped and it “made a straight line” toward the ground. The airplane “corkscrewed” straight down and went out of view. The witness said the airplane, which he estimated was about 3/4-mile away from him, descended “fast.” From the time he first observed the airplane until it went out of sight was about 8 seconds. The witness described the weather conditions as very windy and cold with good visibility.

A second witness said she heard and saw the airplane flying overhead. The airplane was flying “somewhat erratically.” It eventually flew east over a wooded area, then “turned nose down and spiraled out of sight.”

A couple who was hiking with their dog in the woods stated that the sound of the airplane’s “engine” caught their attention. They both stated that the “airplane’s engine” was really loud and “clunky.” It then shut off, before it restarted. When it restarted, it was much quieter.

Another witness said he heard the engine rpms “fluctuate drastically,” cutting in and out, and the airplane sounded like “it was struggling to stay going.”

According to the husband of the rear-seat passenger, she took a photograph with her mobile phone during the flight about 10 minutes before the accident. The image shows that the pilot receiving instruction was seated in the front left seat with his right hand on the throttle control levers, and the flight instructor was seated in the front right seat. Neither of the flight instructor’s hands appear to be near the engine controls or on the control yoke. Several engine instruments were visible in the photograph and, based on what could be seen of their readings, both engines appear to operating at the time the photograph was taken (see figure 2). The horizon is visible with gray cloud bases above the airplane’s altitude.”

Figure 2: Photograph taken by rear-seat passenger about 10 minutes before the accident.

The flight instructor held an airline transport pilot certificate with a rating for airplane multi-engine land, as well as commercial privileges with ratings for airplane single-engine land and sea, glider, lighter than air (balloon) and rotorcraft-helicopter, with an instrument rating in airplane and rotorcraft helicopter. He also held a flight instructor certificate with ratings for airplane single-engine and multi-engine, rotorcraft-helicopter and gyroplane, and glider, and instrument airplane and rotorcraft helicopter. His last FAA second-class medical certificate was issued on May 4, 2023. A review of his pilot logbooks revealed that he had accrued a total of about 11,662 flight hours. He had about 4,450 total flight hours in multi-engine airplanes, of which about 50 hours were in the same airplane make and model as the accident airplane.

The pilot receiving instruction held a commercial pilot certificate with ratings for airplane single-engine and multi-engine land, and a rating for instrument airplane. A review of his logbook revealed that, as of September 2, 2023, he had logged about 353 total flight hours, of which 9 hours were in a multi-engine airplane. None of these hours were in the same airplane make and model as the accident airplane. The last time the pilot entered a flight in a multi-engine airplane into his logbook was February 2013. His last flight review was July 20, 2023. The pilot was receiving instruction to get current in multi-engine airplane operations. This was his first flight in the airplane, and with the flight instructor.

Weather reported at Orange Municipal Airport (ORE), Orange, Massachusetts, about 12 miles east of the accident site, at 1152, included wind from 220° at 11 kts gusting to 23 kts, visibility 10 miles, broken clouds at 4,600 ft, temperature 2°C, dew point of -7° C, and a barometric pressure setting of 29.68 inches of mercury.

At the time of the accident, two AIRMETs were issued and active, including AIRMET Zulu for moderate icing conditions.

There was also a SIGMET for occasional severe turbulence between 3,000 and 16,000 ft msl due to strong low-level winds.

The Beech 95-B-55 was a six-seat, twin-engine airplane that was powered by two Continental IO-470-L reciprocating engines. A unique design with this airplane model, as compared to most other light twin-engine airplanes, was the layout of the power quadrant (engine controls). The throttle control levers were in the middle, with the propeller control levers on the left and mixture control levers on the right, making the throttle control levers equally accessible to both front seat occupants. (Most other light twin-engine airplanes had the throttle control levers on the left, the propeller control levers in the middle, and the mixture control levers on the right.)

The airplane was equipped with pilot-operated deice and anti-ice systems. The windshield and both propeller systems had anti-icing (alcohol) systems, and the pitot had an integral heating element. Both wings, both horizontal stabilizers, and the vertical stabilizer were equipped with inflatable pneumatic deice boots.

The airplane impacted terrain located in the Leyden Wildlife Management Area. It came to rest in a clearing on a shallow hill on a magnetic heading of about 260°. All major components of the airplane were located at the accident site, and there was no postimpact fire. The disposition of the wreckage was consistent with the airplane landing in a relatively flat attitude with little forward movement. Both wings, along with their respective engines and propeller systems, remained attached to the fuselage. The right wing impacted a tree about mid-span. The tail section was partially separated from the empennage but remained attached via control cables.

A review of photos taken by the Massachusetts State Police upon their arrival on scene about 2.5 hours after the accident revealed some airframe icing on the airplane’s left wing, left engine cowling, and nose baggage area.

An on-scene investigation conducted the following morning found the airplane covered with a light coating of dry snow due to snow squalls that had moved through the area after the accident. Once the snow was brushed away, some airframe icing was observed on the leading edge of both horizontal stabilizers, the leading edge of the rudder, and both wings. Ice was also observed on the left and right engine cowlings, the front face of one propeller blade on the left engine, and the navigational antennas located on the vertical stabilizer.

Flight control continuity was established from the flight control surfaces to their respective controls in the cockpit. The right rudder cable and trim cable were found broken in tensile overload and exhibited broomstraw-type fracture features (unraveling of the individual fractured cable strands). The flap shaft cables from the motor to the flap actuators was also confirmed.

The top portion of the cabin area had been peeled back by rescue personnel to recover the three occupants. The landing gear and flaps were found retracted, which was also confirmed by measuring the extension of their respective actuators. The aileron trim tab was measured to be 0°(neutral), and the elevator trim was 2° tab up on the left and 5° tab up on the right. The right elevator was partially separated from the right horizontal stabilizer. The rudder trim was 4° tab right.

Impact damage precluded examination of the windshield anti-icing system and the inflatable pneumatic deice boots on the wings, horizontal stabilizers, and vertical stabilizer.

The windshield anti-ice switch was in the “off” position, and the propeller anti-ice, pitot heat, and ice detect light switches were impact damaged. The position of the surface deice switch could not be determined because it is a momentary switch (which has no “on” or “off” position but activates as a one-time cycle when pressed).

Both wings sustained impact damage, and both fuel bladder tanks were breached and empty of fuel.

The fuel selector valves and handles were found and verified to be in the “on” position, and continuity of the fuel system was confirmed to each engine.

The right and left engines and their respective two-blade propeller systems were each examined as an individual unit. Both engines’ crankshafts rotated freely via their respective propeller. When manually rotated, thumb compression and valvetrain continuity were established to each cylinder. All four magnetos remained secure to their respective engine; spark was produced to all ignition leads. The spark plugs were removed and exhibited normal wear as per the Champion Check-A-Plug chart. The fuel injector nozzles were also removed, and all were free and clear of debris. Oil was observed in both engines, and no metallic debris was noted in either oil filter. The engine-driven fuel pumps, throttle body, fuel metering valve and fuel flow divider showed evidence of fuel. Fuel was noted in the fuel divider both for both engines and was absent of debris and water when tested. All fuel screens were absent of debris.

The right engine propeller had one blade that was undamaged, and the other was bent aft and exhibited a dent about mid-span on the trailing edge. Both of the left engine’s propeller blades were undamaged, except for a small dent on the trailing edge of one blade.

An electronic engine monitor was recovered from the airplane and sent to the NTSB Recorders Laboratory for download. No data were recorded since the unit was an older model that was not equipped with a memory module.

No preimpact mechanical deficiency or malfunction was observed with the airplane or the engines that would have precluded normal operation.

According to FAA records, the flight instructor reported using lisinopril, chlorthalidone, atorvastatin, esomeprazole, acetaminophen, fluticasone, and hydrocortisone ointment at his last FAA medical examination in 2023. He was issued a second-class medical certificate with the limitation that he must wear corrective lenses to meet vision standards at all required distances.

According to the flight instructor’s FAA medical certification file, he had been arrested and convicted multiple times for driving under the influence (DUI) driving offenses. The last documented arrest and conviction reported to the FAA was in 2004. This conviction resulted in the FAA requesting the flight instructor to surrender his medical certificate. After several years of rehabilitation and close medical monitoring, an authorization of special issuance and a letter of eligibility from the FAA, the flight instructor’s medical certificate was renewed in 2007.

The flight instructor’s personal medical records from his primary care physician’s practice were reviewed for the 3 years before the accident. In the first visit note reviewed from May 2021, he was treated for anxiolytic (benzodiazepine) dependence, a generalized anxiety disorder, insomnia, high blood pressure, and seasonal allergies. The flight instructor’s medication list at that time included lisinopril, chlorthalidone, atorvastatin, alprazolam, zolpidem, and citalopram. In June 2021, the flight instructor was involved in a motor vehicle crash and, on evaluation in the emergency department, was found to be intoxicated by alcohol. At his last clinic visit reviewed in 2023, the flight instructor’s medication list continued to include alprazolam, zolpidem, and citalopram.

An autopsy was conducted on the flight instructor by the Commonwealth of Massachusetts, Office of the Chief Medical Examiner. The cause of death was determined to be multiple blunt force injuries, and the manner of death was an accident.

The FAA Forensic Sciences Laboratory performed toxicological testing of postmortem specimens for the flight instructor. Alprazolam was detected in cavity blood at 62 ng/mL and detected in urine at 1016 ng/mL. Alpha-hydroxyalprazolam was not detected in cavity blood and was detected in urine at 730 ng/mL. Amitriptyline was detected in cavity blood at 27 ng/mL and was detected in urine at 187 ng/mL. Nortriptyline was detected in cavity blood at 19 ng/mL and was detected in urine at 81 ng/mL. Zolpidem was detected in cavity blood at 136 ng/mL and detected in urine at 467 ng/mL Citalopram was detected in cavity blood at 1416 ng/mL and in urine at 29625 ng/mL. N-desmethylcitalopram was detected in cavity blood and was detected in urine at 5653 ng/mL. Atorvastatin, lisinopril, and indomethacin were detected in cavity blood and urine. Ethanol was not detected.

Alprazolam is a potent prescription benzodiazepine medication commonly used to treat generalized anxiety disorders and panic disorders. Alprazolam is a federal Schedule IV controlled substance with a potential for dependence and withdrawal. Alprazolam medications typically carry a warning that use depresses CNS function, and that users should be cautioned against engaging in hazardous occupations requiring mental alertness such as operating machinery or driving a motor vehicle. In addition to medicinal use, alprazolam is commonly misused. Alpha-hydroxyalprazolam is a less-potent active metabolite of alprazolam. The FAA considers alprazolam a “Do not issue/Do not fly” medication.

Amitriptyline is a prescription tricyclic antidepressant that can be used to treat major depression. Amitriptyline medications commonly carry a warning that the user should be advised as to the possible impairment of mental abilities, physical abilities, or both required for performance of hazardous tasks, such as operating machinery or driving a motor vehicle. The FAA considers amitriptyline a “Do not issue/Do not fly” medication.

Zolpidem is a prescription medication commonly used to treat short-term insomnia. It generally carries a warning that use may impair the ability to operate a motor vehicle or heavy machinery, including the next day after use. Drowsiness, prolonged reaction time, dizziness, blurred vision, and reduced alertness have been reported the next day after use in some patients. Use with other CNS depressants such as alprazolam is recommended to be avoided as CNS depressant effects will be additive. The FAA considers occasional or limited use of sleep aids, including zolpidem, allowable for pilots, provided they do not use the drug every day and they observe a sufficient waiting period for the drug to be cleared from circulation before flying.

Citalopram is a prescription medication commonly used to treat major depression. Major depression can cause cognitive impairment, particularly of executive function. Antidepressant treatment may improve such impairment. In healthy individuals, studies of citalopram have not established that it causes cognitive or psychomotor impairment. However, citalopram sometimes carries a warning that any psychoactive drug may impair judgment, thinking, or motor skills, and that users should be cautioned about operating hazardous machinery, until they are reasonably certain that citalopram does not affect their ability to engage in such activities. A pilot on citalopram may be considered for FAA medical certification via authorization for special issuance only, due to the required detailed evaluation of the individual pilot’s condition, including assessment of the pilot’s cognitive function and response to medication. Caution is also advised in using amitriptyline in combination with other anti-depressants such as selective serotonin-reuptake inhibitors as a result of increased risk of complications such as cardiac rhythm abnormalities, and confusion. If used together, close medical monitoring is recommended.

Atorvastatin is prescription medication commonly used to treat high cholesterol. Lisinopril is a prescription medication commonly used to treat high blood pressure and indomethacin is a prescription non-steroidal anti-inflammatory drug commonly used to treat symptoms of arthritis. Atorvastatin, lisinopril, and indomethacin are not generally considered impairing.

An autopsy was conducted on the pilot receiving instruction by the Commonwealth of Massachusetts, Office of the Chief Medical Examiner. The cause of death was determined to be multiple blunt force injuries, and the manner of death was an accident.

Toxicology testing conducted by the FAA Forensics Laboratory identified Naproxen in the pilot receiving instruction’s blood and Desloratadine in his urine. Naproxen is an over-the-counter pain reliever, and Desloratadine is a prescribed, nondrowsy allergy medicine found in Claritin. Neither drug is considered to be impairing.

The NTSB conducted an airplane performance study to analyze the motion of the airplane and attempt to define the airplane’s position and orientation during the relevant portion of the flight and to determine the airplane’s response to control inputs, external disturbances, ground forces, and other factors that could affect its trajectory.

Specifically, because an airplane must be in a stalled condition before it can spin, and because a spin entry requires the presence or introduction of a yawing moment at the stall, the study considered possible conditions and scenarios that could affect the airplane’s stall performance and produce a yawing moment. The study used the available ADS-B data, wreckage location and condition, weather information, airplane performance information from AFM, and estimated weight load for the accident airplane to support the analysis.

The performance study determined that the accident airplane entered two stalls in the minute before the accident. The airplane was successfully recovered from the first stall but not the second, during which a spin developed and continued to ground impact.

The study determined that, during each stall, the airplane achieved the nominal flaps-up stall speed outlined in the AFM. As such, there was no evidence that airframe icing contamination adversely affected the airplane’s stall speed. Further, since the first stall was successfully recovered just moments (about 24 to 29 seconds) before the second stall was initiated, there is no evidence to suggest that ice contamination resulted in other adverse aerodynamic characteristics, such as asymmetric stall behavior (one wing stalling before the other), which may result in a yawing moment.

In addition, the study determined that the computed engine power required during the time surrounding the first stall exceeded the power available from one engine, indicating that both engines must have been operating at the time of the first stall. This is inconsistent with a scenario involving a Vmc demonstration, which is a demonstration (commonly performed during multi-engine airplane instructional flights) of the airplane’s minimum control airspeed with one engine deliberately shut down or set to minimum thrust, which may result in a yawing moment.

The study determined that, at the time of the second stall, the required engine power was reduced compared to that required during the approach to the first stall. The oscillations in the required power calculation before the second stall increased the difficulty in determining the power level present at the stall. However, given that the second stall occurred less than 30 seconds after the first, the study concluded that it was “very unlikely” that the second stall was associated with an attempted Vmc demonstration or that the pilots were attempting a single-engine stall (the latter of which the AFM states should not be done “by other than qualified engineering test pilots”).

Having excluded an asymmetrical aerodynamic condition and asymmetrical engine thrust as potential sources of the yawing moment that induced the airplane’s spin, the study concluded that the spin may have resulted from an improper stall recovery technique, possibly involving an excessive or inadvertent rudder input.

According to chapter 13 of the FAA’s Airplane Flying Handbook, FAA-H-8083-3C, “no multiengine airplane is approved for spins, and their spin recovery characteristics are generally very poor. It is therefore prudent to practice spin avoidance and maintain a high awareness of situations that can result in an inadvertent spin.” The handbook references stall practice and Vmc demonstrations as among the scenarios in which “spin awareness must be at its greatest.”

With regard to practicing stalls in a multi-engine airplane, the handbook states that, “when the airplane reaches the stall warning [such as an aural alert or buffet],” the recovery is made by first reducing the airplane’s [angle of attack] until the stall warning is eliminated.”

The handbook also states that:

“…as very few [twin-engine airplanes] have ever been spin-tested (none are required to), the recommended spin recovery techniques are based only on the best information available. The departure from controlled flight may be quite abrupt and possibly disorienting….If a spin is entered, most manufacturers recommend immediately retarding both throttles to idle, applying full rudder opposite the direction of rotation, and applying full forward elevator/stabilator pressure (with ailerons neutral). These actions should be taken as near simultaneously as possible. The controls should then be held in that position until the spin has stopped….Pilots should be aware that a spin recovery will take considerable altitude; therefore, it is critical that corrective action be taken immediately.”