N412ES

HISTORY OF FLIGHT

On November 24, 2008, about 1045 central standard time, a Beech 95-B55, N412ES, registered to and operated by a private individual, experienced an in-flight loss of control and crashed into a wooded area behind a house in Whites Creek, Tennessee. Instrument meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 business flight from Memorial Field Airport (HOT), Hot Springs, Arkansas, to Nashville International Airport (BNA), Nashville, Tennessee. The airplane was destroyed by impact and a postcrash fire and the certificated commercial pilot and 2 passengers were killed. The flight originated about 0909, from HOT.

Before takeoff, the pilot contacted the Memphis Air Route Traffic Control Center and requested IFR clearance to the destination airport. The pilot was instructed that the flight was cleared as filed, to climb and maintain 5,000 feet, expect 7,000 feet ten minutes after departure, instructed as to the discrete transponder code (5524), and advised of the clearance void time. The pilot correctly read back the clearance, and at 0911, he established contact with the facility and advised the controller that the flight was climbing through 2,500 feet. The flight was radar identified and instructed to climb to 7,000 feet continuing towards the destination airport.

Air traffic control (ATC) communications were transferred to several ATC facilities and at approximately 1024, while in contact with the Memphis Air Route Traffic Control Center, the pilot was instructed to descend and maintain 4,000 feet. At approximately 1032, ATC communications were transferred to the Nashville Air Traffic Control Tower, and at 1033:12 while in contact with that facility, the pilot advised the controller that the flight was at 4,000 feet. Radar data indicated that the pilot maintained approximately 4,000 feet from 1032:53 until 1044:12. The controller acknowledged the pilot contact and advised him that the automated terminal information service (ATIS) sierra was current and to expect vectors for an ILS approach to runway 20R at the destination airport. The pilot correctly read back the ILS runway designator and approximately 3 minutes later, at 1036:24, the pilot was instructed to fly heading 055 degrees for sequencing, which he also correctly read back. The radar data indicated that from 1037:21, to 1042:21, the airplane proceeded on the approximate heading instructed by the controller, but beginning at 1042:30, heading deviation left of the assigned course was noted.

At 1042:58, the controller advised the pilot of the location of another airplane and the pilot responded at 1043:05, "yeah well I’m all screwed up up here so stick with me." The controller asked the pilot if he needed assistance and the pilot asked the controller how far he was from the localizer. The controller advised the pilot that the flight was 12 miles from the localizer and asked the pilot to make sure he wasn’t confusing the John Tune Airport localizer setting (110.3 MHz) with the BNA Airport runway 20R localizer setting of 111.3 MHz. While the transcription of communications indicates the pilot responded at 1043:43 with, "(unintelligible) again one eleven three", Safety Board review of the voice tape from the facility revealed the pilot replied with words to the effect that he had 111.3 selected.

The controller then instructed the pilot to fly his present heading and to expect a base and final turn to the localizer; the pilot did not respond. The controller again advised the pilot to expect a base turn in 5 miles and a turn south onto the localizer. The transcription of communications indicates the pilot replied "gotcha." At 1044:24, the controller repeated the partial call sign of the airplane, and the pilot responded, "two echo sierra I’ve got you but I'm having trouble hold." A pause was noted and then grunting sounds were recorded on the frequency. The controller asked the pilot if he needed help and he responded, "I got it into a spin and I can’t stop it." Heavy breathing/grunting sounds for several seconds were heard on the frequency. At 1044:54, the controller advised the pilot to climb immediately to 3,000 feet. The pilot responded with "got no climb." At 1045:09, the controller again advised the pilot to climb immediately; there was no further response from the pilot. The controller broadcast on the frequency advising the pilot that the flight was 6 miles north of John Tune Airport, and that rescue vehicles had been dispatched.

According to the controller who was communicating with the accident pilot, he noticed the pilot was not tracking his assigned heading, and then noticed a descent from the assigned altitude below the minimum vectoring altitude. He issued climb instructions and reported the accident airplane kept descending. He marked the aircraft's position and asked to be relieved from his position.

Radar data correlated with the transcriptions of communications revealed that at 1042:30 which was approximately 35 seconds before the pilot first advised the controller of a discrepancy, the airplane's heading changed to the left without instruction from ATC to a maximum northerly heading of 023 degrees which occurred at 1043:03. The airplane then turned to 030 degrees and remained on that heading for 3 radar returns between 1043:08 and 1043:17. Between 1043:21 and 1043:31, the airplane turned to the right flying the approximate heading instructed previously by the controller (055 degrees), and between 1043:31 and 1044:12, heading changes to the left and right were noted as well as a decrease in groundspeed to 155 knots. Between 1044:12, and 1044:27 which was the approximate time the pilot advised the controller that he was "…having trouble hold", the radar data indicates that the airplane's heading changed from 051 degrees to 344 degrees, the altitude decreased from 4,000 to 3,700, and the groundspeed decreased from 155 to 145 knots.

Further review of the radar data correlated with the transcription of communications revealed that between 1044:27, and 1044:40 which was the time the pilot advised the controller that the airplane was in a spin and couldn't stop it, the radar data reflected that the heading changed from 344 degrees to 035 degrees, altitude deviations between 3,700 and 3,500 were noted, and the groundspeed decreased from 139 to 107 knots. Between 1044:40 and 1045:03 (last correlated radar return), heading changes left and right were noted, the altitude decreased from 3,500 to 1,300 feet, and the groundspeed decreased from 107 to 51 knots. The last radar target was located at 036 degrees 17 minutes 22.01 seconds North latitude and 086 degrees 50 minutes 38.38 seconds West longitude, at an altitude of 1,300 feet. The accident site was located approximately 52 degrees and 0.04 nautical mile from the last radar return.

A witness located near the crash site reported he was inside his house and heard an airplane that sounded abnormal; the witness and his son reported hearing a whirring sound. The witness looked outside his window and saw the airplane flying in a southwesterly direction. The abnormal sound faded momentarily, and then returned. The airplane began spinning in a counterclockwise direction and was flat while spinning. He estimated the airplane spun 4 times before losing sight. Each 360 degree rotation took approximately 1 second. He called 911 and ran to the scene. When he arrived there he noticed a fire at the front of the airplane which spread out. He estimated the fire department arrived in 5 minutes. The witness further reported the weather condition at the time consisted of low clouds with light drizzle.

PERSONNEL INFORMATION

The pilot, age 67, held a commercial pilot certificate with airplane single engine land, airplane multi-engine land, and instrument airplane issued June 28, 2002. His most recent

special issuance third class medical certificate was issued November 21, 2008, with limitations to have available glasses for near vision.

The pilot reportedly kept his pilot logbook inside the cockpit; the logbook was not located during the inspection of the wreckage. He listed 1,990 hours of total flight time on the application for his latest medical certificate. While no pilot logbook was located, correlation of the pilot's flight time based on maintenance record entries revealed the airplane had been operated approximately 20 hours between November 1, 2007, and May 26, 2008 which was the last entry in the engine logbooks.

The pilot was paid on a monthly basis to fly the passengers on business trips when needed. During those trips, the pilot's fuel costs, lodging and meals were also paid for by the passenger's company.

AIRCRAFT INFORMATION

The airplane was manufactured in 1978, by Beech Aircraft Corporation, as model 95-B55, and was designated serial number TC-2198. It was powered by two Teledyne Continental Motors IO-520-E engines rated at 260 horsepower and 2,700 rpm for maximum continuous operation that were installed in accordance with (IAW) Supplemental Type Certificate (STC) SA432SO. The flight manual supplement (FMS) associated with the STC indicated the normal operating (green arc) range was 2,000 to 2,700 rpm. It was also equipped with two Hartzell HC-EHC-G3YF-2UF propellers, which are single-acting, hydraulically operated, constant speed with manual feathering capability.

Review of the airframe maintenance records revealed the last entry pertaining to the transponder, altimeter, and pitot static system tests in accordance with 14 CFR Part 91.411, and 91.413 was logged as occurring on June 24, 2003. The work was performed by a Federal Aviation Administration (FAA) approved certified repair station. While there was no further entry in the airframe logbook indicating the transponder, altimeter, and pitot static systems were checked after that date, an individual who knew the...