N678DM

HISTORY OF FLIGHTOn August 18, 2019, about 0851 eastern daylight time, a Beech 95-B55, N678DM, was substantially damaged when it was involved in an accident near Wilmington, Delaware. The pilot and the flight instructor were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight.

The airplane was departing New Castle Airport (ILG), Wilmington, Delaware. Air traffic control radio communication data provided by the Federal Aviation Administration (FAA) indicated the pilot established communication with the tower controller at ILG, who cleared the airplane for takeoff from runway 32 and instructed the pilot make left traffic. About 1 minute later, the pilot advised that during takeoff, a door popped open. The controller instructed the pilot to make a 180° turn and back-taxi on runway 32. About 2 minutes later, the pilot requested to take off from runway 32, and the controller cleared the flight for takeoff. About 2 minutes later, the pilot advised the controller that he was returning to the runway; however, he did not specify a reason or declare an emergency. The controller cleared the flight to land on any runway. The controller then gave a wind check and attempted to contact the pilot but received no response.

A witness driving on a nearby interstate reported that he saw the airplane “nose diving” and heading straight down into trees.

PERSONNEL INFORMATIONA review of the pilot’s logbook, which was recovered in the wreckage, indicated he had recorded about 586 total hours of flight experience, with 72 hours of multi-engine experience through the date of the last logbook entry on June 22, 2019.

The flight instructor’s logbook was not recovered. On the application for his most recent second-class medical certificate, dated October 29, 2018, he reported 8,900 total hours of flight experience, including 115 hours in the previous 6 months.

AIRCRAFT INFORMATIONThe airplane was equipped with an optional fuel tank installation. The Beechcraft Baron B55 pilot’s operating handbook (POH), section VII, Systems Description – Fuel System, indicated that the optional fuel tank installation consisted of a 37-gallon main tank in each wing leading edge and a 31-gallon auxiliary tank in each wing panel outboard of the nacelle, for a total of 136 gallons of useable fuel (if all tanks were full). The POH further stated, “The separate, identical fuel supplies for each engine are interconnected by crossfeed lines. During normal operation each engine uses its own fuel pumps to draw fuel from its respective fuel tank arrangement. However, on emergency crossfeed operations the entire fuel supply of any or all tanks can be consumed by either engine.”

The POH, section III, Emergency Procedure – Engine Failure, includes the following checklist for engine failure after lift-off and in flight:

“An immediate landing is advisable regardless of take-off weight. Continued flight cannot be assured if take-off weight exceeds the weight determined from the TAKE-OFF WEIGHT graph. Higher take-off weights will result in a loss of altitude while retracing the landing gear and feathering the propeller. Continued flight requires immediate pilot response to the following procedures.

Landing Gear and Flaps – UP

Throttles (inoperative engine) – CLOSED

Propeller (inoperative engine) – FEATHER

Power (operative engine) – AS REQUIRED

Airspeed – MAINTAIN SPEED AT ENGINE FAILURE (100 KTS (115 MPH) MAX.) UNTIL OBSTACLES ARE CLEARED

After positive control of the airplane is established:

Secure inoperative engine:

Mixture Control – IDLE CUT-OFF

Fuel Selector – OFF

Fuel Boost Pump – OFF

Magneto/Start Switch – OFF

Generator/Alternator – OFF

Cowl Flap – CLOSED

Electrical Load – MONITOR (Maximum load of 1.0 on remaining engine).

NOTE

The most important aspect of engine failure is the necessity to maintain lateral and directional control. If airspeed is below 78 kts (90 mph), reduce power on the operative engine as required to maintain control.”

AIRPORT INFORMATIONThe airplane was equipped with an optional fuel tank installation. The Beechcraft Baron B55 pilot’s operating handbook (POH), section VII, Systems Description – Fuel System, indicated that the optional fuel tank installation consisted of a 37-gallon main tank in each wing leading edge and a 31-gallon auxiliary tank in each wing panel outboard of the nacelle, for a total of 136 gallons of useable fuel (if all tanks were full). The POH further stated, “The separate, identical fuel supplies for each engine are interconnected by crossfeed lines. During normal operation each engine uses its own fuel pumps to draw fuel from its respective fuel tank arrangement. However, on emergency crossfeed operations the entire fuel supply of any or all tanks can be consumed by either engine.”

The POH, section III, Emergency Procedure – Engine Failure, includes the following checklist for engine failure after lift-off and in flight:

“An immediate landing is advisable regardless of take-off weight. Continued flight cannot be assured if take-off weight exceeds the weight determined from the TAKE-OFF WEIGHT graph. Higher take-off weights will result in a loss of altitude while retracing the landing gear and feathering the propeller. Continued flight requires immediate pilot response to the following procedures.

Landing Gear and Flaps – UP

Throttles (inoperative engine) – CLOSED

Propeller (inoperative engine) – FEATHER

Power (operative engine) – AS REQUIRED

Airspeed – MAINTAIN SPEED AT ENGINE FAILURE (100 KTS (115 MPH) MAX.) UNTIL OBSTACLES ARE CLEARED

After positive control of the airplane is established:

Secure inoperative engine:

Mixture Control – IDLE CUT-OFF

Fuel Selector – OFF

Fuel Boost Pump – OFF

Magneto/Start Switch – OFF

Generator/Alternator – OFF

Cowl Flap – CLOSED

Electrical Load – MONITOR (Maximum load of 1.0 on remaining engine).

NOTE

The most important aspect of engine failure is the necessity to maintain lateral and directional control. If airspeed is below 78 kts (90 mph), reduce power on the operative engine as required to maintain control.”

WRECKAGE AND IMPACT INFORMATIONThe accident site was located about 2.1 nautical miles northwest of the runway 32 threshold. Examination of the wreckage at the accident site revealed that the airplane impacted trees and then terrain in a nose-low and inverted attitude. An odor of 100LL aviation fuel was noted on site. Two sections of the right wing were separated and were found in a tree about 30 ft above the ground near the main wreckage. Flight control cable continuity was established from all control surfaces to the cockpit. The left and right aileron bellcranks displayed fracture features consistent with overload and all cable ends remained attached to their fittings. All three landing gear were retracted, and the landing gear switch was in the retracted position.

The right fuel selector was found in the "main" position. The left fuel selector was found between the “main” and “crossfeed” positions. Both fuel selector valves were removed from the airplane, and air was blown through to determine position. The right fuel selector valve was confirmed on the main (right) tank. The left fuel selector valve had no airflow when air was introduced through the crossfeed port; when air was blown through the main port, airflow was restricted. Fuel was drained from the right fuel strainer and tested; no water was detected with a water-finding paste. No fuel was observed in the left fuel strainer. All fuel caps were found closed and secured. The four fuel tanks were breached and absent of fuel.

For both the left and right engine, the throttles were found in the full forward position, the mixture controls were fully rich, and the propeller controls were at the high rpm settings. Both ignition switches were found in the “on” position.

The left engine remained partially attached to the airframe through wires, hoses, and cables. There were no signs of a catastrophic internal engine failure. The crankshaft was rotated using a hand tool, and valvetrain continuity was established. After the cylinders were removed, the exposed portions of the crankshaft were visually inspected; the visible portions displayed normal operating and lubrication signatures. The fuel pump was functionally tested and capable of pumping fuel. The magnetos were tested and produced spark on all towers.

The left propeller remained partially attached to the propeller flange; one propeller blade displayed minor chordwise scratches and the blade tip was bent about 90° forward. The other propeller blade was bent aft and was loose in the hub.

The right engine remained partially attached to the airframe through cables, hoses, and wires. There were no signs of a catastrophic internal engine failure. The crankshaft was rotated using a hand tool, and valvetrain continuity was established. The fuel pump was functionally tested and capable of pumping fuel. The magnetos were tested and produced spark on all towers.

The right propeller had almost completely pulled free from the crankshaft. One propeller blade displayed minor twisting and aft bending deformation. The other propeller blade displayed S-bending deformation.

MEDICAL AND PATHOLOGICAL INFORMATIONThe FAA Forensic Sciences Laboratory performed toxicology testing on the pilot’s tissue samples; sertraline and desnethylsertraline were detected in blood and urine specimens. Sertraline is an antidepressant in a group of drugs called selective serotonin reuptake inhibitors. Desmethylsertraline, also known as norsertraline, is an active metabolite of sertraline. Sertraline is a prescription medication indicated for the treatment of depression, post-traumatic stress disorder, panic disorder, social anxiety disorder and obsessive-compulsive disorder. Sertraline carries the warning that use may impair the mental and physical ability to perform hazardous tasks.

The FAA Forensic Sciences Laboratory performed toxicology te...