N495AU

HISTORY OF FLIGHT

On October 31, 2022, at 1304 eastern daylight time, a Beech G58 multi-engine airplane, N495AU, was destroyed when it was involved in an accident in Alpharetta, Georgia. The pilot and the passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

A review of ATC communications and automatic dependent surveillance–broadcast flight tracking data provided by the Federal Aviation Administration (FAA) indicated the airplane was being provided with radar vectors for the ILS or LOC RWY 21L instrument approach into DeKalb-Peachtree Airport (PDK), Atlanta, Georgia.

When the airplane was about 5 miles from the final approach fix, ATC instructed the pilot to turn left heading 240°, maintain 3,000 ft msl until established on the localizer, and issued an approach clearance. The pilot did not read back the altitude assignment in the clearance. The controller again instructed the pilot to maintain 3,000 ft msl until established on the approach and re-stated the approach clearance. The pilot acknowledged with the airplane’s call sign only.

The airplane was then observed to climb to 3,200 ft msl before it began to descend. The air traffic controoler received a MSAW alert when the airplane descended through 2,400 ft msl, and the controller immediately instructed the pilot to check the airplane’s altitude and to start climbing. The pilot responded that he was climbing and “going around.” The controller instructed the pilot to climb to 3,000 ft msl, turn 330°, and to keep “wings level.” The pilot repeated the instructions. The pilot then initiated a climbing right turn to 3,200 ft msl, before entering a descending left turn. The controller continued to receive low altitude alerts and made numerous attempts to contact the pilot, but there was no further communication with him. The airplane continued to descend, before it was no longer observed on radar. The airplane’s last radar return was received at 1304:19. At that time, the airplane was at an altitude of 1,325 ft msl, about 355 ft above ground level (agl), on a ground track of 252°, and at a ground speed of 215 knots (247 mph).

A witness, who is a pilot, was in his apartment near the accident site when he heard the airplane’s engines running at a high rpm, followed by a “loud metallic bang.” He looked out his window and could not see if the airplane had crashed but did observe the weather to be overcast with a low ceiling.

Another witness was walking home when he first heard the airplane. He said the engine(s) sounded “powerful and even, with no sputtering or skipping.” The witness looked up but was initially unable to see the airplane due to the “heavy” and low cloud cover. When the airplane crossed directly in front of him, it broke through the cloud cover. The wings were level and there was no smoke, fire, or anything trailing behind the airplane. The nose of the airplane was pointed “slightly” down towards the ground, and it was moving “very fast.” The witness said the airplane continued to descend under high engine power before it impacted the ground. He said, “At no time did I see or hear any change in engine power, angle of descent or direction of travel. The aircraft simply flew into the ground, with no visible attempt by the pilot to turn or pull up.” The witness thought that the pilot had time to realize his proximity to the ground, once clear of the cloud cover, and a brief time in which to react. He said, “I kept thinking that I would see the aircraft nose up into a climb, but this did not occur.”

PILOT INFORMATION

The 76-year-old pilot held a commercial certificate with ratings for airplane single-engine land and sea, airplane multi-engine land, and instrument airplane. He also held a mechanic certificate with airframe and powerplant ratings.

According to the FAA, the pilot’s last second-class medical examination was on May 7, 2021. At the time of exam, he reported a total of 4,850 hours. The pilot reported using the medication pitavastatin, a medication commonly used to treat high cholesterol. He also reported a medical history including moderate aortic valvular stenosis and had an associated murmur on physical exam. The Aviation Medical Examiner deferred the medical certification decision to the FAA. The FAA’s review of the pilot’s aortic stenosis discovered that the pilot had been treated for many years for CLL. The FAA granted the pilot an Authorization for Special Issuance for his CLL and heart murmur in November 2021. The pilot was issued a second-class medical certificate limited by a requirement that he must wear corrective lenses, and not valid after May 31, 2022. Although the medical certificate had expired at the time of the accident, the pilot completed a BasicMed Course on May 18, 2021, and reported completing a BasicMed Comprehensive Medical Examination Checklist on May 18, 2021.

A pilot logbook was located in the wreckage; however, it was not complete. The first entry was made on December 20, 2019, and the last entry was December 31, 2019. There were no flight endorsements in the logbook, except for an instrument proficiency check that was conducted on December 21, 2019.

The pilot’s flight instructor confirmed that he gave the pilot an instrument proficiency check on January 19, 2022, and a flight review on October 20, 2021. The instructor said that he considered the pilot to be proficient at instrument flying and with operating a technically advanced airplane, such as the Beech G58, without an over reliance on the autopilot. He said that he had listened to the ATC recordings of the accident and felt that the pilot had a “medical incapacitation of some sort.”

METEOROLOGICAL INFORMATION

At 1300, a special weather observation was issued at PDK. The weather was reported as wind from 360 degrees at 5 knots, visibility 2 ½ miles, mist, ceiling overcast at 200 ft agl, temperature 17 degrees C, dew point temperature 16 degrees C, altimeter 30.01 inches of mercury.

WRECKAGE INFORMATION

The airplane impacted wooded terrain on a magnetic heading of 252° about 16 miles northwest of PDK. The initial impact point was a stand of trees that were about 60 feet-tall. The airplane continued to impact trees as it descended before it impacted the ground. Numerous pieces of angular cut wood were located along the wreckage path.

The airplane impacted the ground and was heavily fragmented consistent with a high-energy impact. Both engines were buried about 4 ft in the ground. The airplane’s seats and portions of the cockpit were also located in the impact crater with the engines. Fragmented sections of the airplane’s wings, fuselage, and tail section were found around and forward of the main wreckage. Despite the fragmentation, all major components of the airplane were located at the accident site. There was no postimpact fire.

The fuselage, cockpit area, and empennage were destroyed by impact. The tail section sustained extensive impact damage. Partial flight continuity was established for the rudder to the bellcrank. Numerous breaks of the tail section flight control cables were observed. The breaks exhibited fracture features consistent with overload. The elevator trim tab actuator was not located. The rudder trim tab actuator was in the “neutral” position.

Both wings sustained extensive impact damage and were heavily fragmented. Flight control continuity could not be established due to impact, but numerous breaks in the cable system were observed. These breaks exhibited broom-straw fracturing consistent with tensile overload. Each wing has two flap actuators; however, only one actuator for each wing was located. Both actuators were consistent with the flaps being fully retracted.

The landing gear were damaged from impact and separated; however, the gear box was examined and was consistent with the gear being fully retracted.

The airplane was equipped with a Garmin G-1000NXI. The multi-function display SD card was located in the wreckage and shipped to the National Transportation Safety Board Recorders Lab for download. Due to impact damage, no data could be extracted from the card.

MEDICAL AND PATHOLOGICAL INFORMATION

The pilot’s autopsy was performed by the Fulton County Medical Examiner. The cause of death was determined to be “generalized blunt force trauma,” and his manner of death was accident. The autopsy was severely limited for evaluation of natural disease by the extent of the pilot’s injuries, which prevented evaluation of his lungs, brain, heart, and other internal organs. A death investigation report accompanying the autopsy report documented that the pilot’s family reported that he had a medical history including hypertension, CLL, mini-stroke, and prostate cancer. The family also reported that the pilot had recently seen a medical oncologist and had not “been well” for the past six months.

The FAA Forensic Sciences Laboratory performed toxicology testing of postmortem muscle tissue of the pilot. Ethanol was detected at 0.017 g/hg. Alfuzosin was also detected.

Ethanol is a type of alcohol. It is the intoxicating alcohol in beer, wine, and liquor, and, if consumed, can impair judgment, psychomotor performance, cognition, and vigilance. FAA regulation imposes strict limits on flying after consuming ethanol, including prohibiting pilots from flying with a blood ethanol level of 0.04 g/dL or greater. Alcohol consumption is not the only possible source of ethanol in postmortem specimens. Ethanol can sometimes be produced by microbes in a person’s body after death. Postmortem ethanol production is made more likely by extensive traumatic injury.

Alfuzosin is a prescription medication commonly used to treat symptoms of an enlarged prostate. Alfuzosin is not generally considered impairing.