N4817M

Substantial
Fatal

Beech 55S/N: TC-2147

Accident Details

Date
Saturday, November 17, 2018
NTSB Number
CEN19FA029
Location
Liberal, KS
Event ID
20181118X65853
Coordinates
37.023384, -100.923000
Aircraft Damage
Substantial
Highest Injury
Fatal
Fatalities
2
Serious Injuries
0
Minor Injuries
0
Uninjured
0
Total Aboard
2

Probable Cause and Findings

The pilot's improper decision to fly in an area where moderate icing conditions were forecasted in an airplane that was not certified for such conditions, and in the effort to get out of the icing conditions, his decision to fly below the minimum descent altitude for the localizer approach to the diversion airport resulting in the airplane impacting a power line and terrain. Contributing was the pilot's inadequate preflight planning.

Aircraft Information

Registration
N4817M
Make
BEECH
Serial Number
TC-2147
Engine Type
Reciprocating
Year Built
1978
Model / ICAO
Aircraft Type
Fixed Wing Multi Engine
No. of Engines
2

Registered Owner (Historical)

Name
DICK JAMES & ASSOCIATES INC
Address
2260 PARK TOWNE CIRCLE STE 204
Status
Deregistered
City
SACRAMENTO
State / Zip Code
CA 95825
Country
United States

Analysis

HISTORY OF FLIGHTOn November 17, 2018, at 1657 central standard time, a Beech 95-B55 airplane, N4817M, was substantially damaged when it was involved in an accident near Liberal, Kansas. The private pilot and the passenger received fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

The flight departed from Montrose Regional Airport (MTJ), Montrose, Colorado, about 1350 and was destined for Dodge City Regional Airport (DDC), Dodge City, Kansas, at a cruise altitude of 15,000 ft. According to air traffic control (ATC) communications, about 1637, while the flight was en route to DDC on a southeast heading and at an altitude of about 6,000 ft, the pilot reported that the airplane picked up "a fair amount" of moderate rime ice, and the controller instructed the pilot to descend to and maintain 5,100 ft.; the pilot acknowledged the instruction. Two minutes later the controller instructed the pilot to fly a heading of 090°; the pilot acknowledged the instruction. About 1642, the pilot contacted ATC and stated that the airplane was accumulating too much ice and that he wanted to climb the airplane to about 8,000 ft to dissipate the accreted ice. The controller instructed the pilot to climb to and maintain 8,000 ft, which the pilot acknowledged. The controller then asked if the ice accumulation was moderate or severe, to which the pilot responded, "yes"; the pilot also stated that the airplane was "not able to climb."

About 1642, the controller asked if the pilot could turn toward Liberal Mid-America Regional Airport (LBL), currently to the north and about 12 miles. The pilot stated to the controller that "we're down to 3,500 feet, VFR [visual flight rules], and we're under control now." The controller then instructed the pilot to proceed direct to LBL, which was 18 miles away on a heading of 044°; the pilot acknowledged the heading. Subsequently, the controller contacted the pilot and asked him to advise if the airplane needed a higher or lower altitude than 3,500 ft; the pilot responded, "maybe a little lower so I can see VFR." The controller then instructed a discretionary altitude direct to LBL.

About 1646, the pilot requested radar vectors for the localizer course to LBL, but the controller could not provide radar vectors due to the airplane's altitude. When the controller informed the pilot that the airplane was 4 miles west of the localizer, the pilot stated that he was using a navigation chart to intercept the localizer. After the pilot reported that the airplane was established on the localizer, the controller canceled the flight's instrument flight rules clearance and terminated radar service. About 1650, the controller asked the pilot to confirm that he had LBL in sight. The pilot stated, "I can't see out of the windshield, I have to get up closer." There were no further recorded communications from N4817M. The airplane subsequently impacted a power line and field about 3 miles south of LBL. AIRCRAFT INFORMATIONThe airplane had an alcohol deice system for the left (pilot)-side windshield and both propellers. The airplane's wings, stabilizer, and right windshield were not equipped with an anti-ice/deice system. The airplane was not certified for flight into icing conditions. METEOROLOGICAL INFORMATIONAIRMET Zulu advisories for moderate ice below 10,000 ft were issued by the National Weather Service's Aviation Weather Center at 1445 and were applicable for the accident airplane's route of flight and the airspace over DDC, LBL, and the accident location.

Leidos Flight Services indicated that it and any third-party vendor that uses the Leidos system had no contact with the accident pilot on the day of the accident.

Pilot reports were publicly disseminated between about 1300 and the accident time for the area within 150 statute miles and below 15,000 ft of the accident location. Numerous pilot reports, including several urgent reports, indicated trace to moderate/severe icing between 3,000 and 7,300 ft. AIRPORT INFORMATIONThe airplane had an alcohol deice system for the left (pilot)-side windshield and both propellers. The airplane's wings, stabilizer, and right windshield were not equipped with an anti-ice/deice system. The airplane was not certified for flight into icing conditions. WRECKAGE AND IMPACT INFORMATIONA photograph taken by the Oklahoma Highway Patrol on the evening of the accident showed that the right (passenger) side window was covered with ice and was opaque. Another photo, taken by a Federal Aviation Administration (FAA) inspector the morning after the accident, showed about ½ inch of ice on the leading edges of the horizontal stabilizer.

The airplane was found upright in a field about 3 miles south of the intended landing runway at LBL. The airplane was located north of a downed power line running west to east. The airplane's landing gear, which was found in the extended position, displayed features consistent with a strike with the power line. The airplane's flaps were fully retracted. Both propellers displayed torsional features consistent with engine operation. Examination of the airframe and engines revealed no preimpact anomalies that would have precluded normal operation.

A 3-gallon alcohol tank for the left windshield deice system was located in the airplane's nose. The tank was dry and exhibited corrosion and dryness of gasket material consistent with long-term non-use. The lines leading from the tank to the pump did not contain fluid and were dry. The alcohol deice pump operated when tested. MEDICAL AND PATHOLOGICAL INFORMATIONThe Office of the Chief Medical Examiner, Oklahoma City, Oklahoma, performed an autopsy of the pilot. His cause of death was multiple acute blunt force injuries.

Toxicology testing performed at the FAA Forensic Sciences Laboratory detected cetirizine in the pilot's urine specimens and losartan in the pilot's blood and urine specimens. No carbon monoxide and ethanol were detected in the pilot's specimens.

Cetirizine is an antihistamine used to relieve allergy symptoms such as watery eyes, runny nose, itching eyes/nose, sneezing, hives, and itching. The toxicology levels of cetirizine were trace amounts and were not quantified. The pilot's use of losartan was previously reported to the FAA and approved.

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# CEN19FA029