ERA24FA088

The flight instructor’s failure to maintain airplane control during a stall, which resulted in an inadvertent spin from which the airplane was not recovered. Contributing to the accident were the overall effect of the flight instructor’s use of multiple central nervous system depressants, the associated underlying conditions they treated, or both.

The flight instructor, commercial-certificated/multi-engine-rated pilot receiving instruction, and a passenger departed on a local flight to practice maneuvers so the pilot could obtain currency in a multi-engine airplane. The pilot receiving instruction had not flown a twin-engine airplane in almost 11 years. This was his first time flying this make/model airplane, and with this flight instructor. Shortly after departure, the airplane climbed to about 3,000 to 3,300 ft mean sea level (msl) and made four alternating left and right 360° turns. After the fourth 360° turn, the airplane began to climb, reaching an altitude of about 4,000 ft msl. The airplane then entered a rapid descent and impacted terrain. Witnesses described that the airplane “corkscrewed” or “spiraled” as it descended nose-down toward the ground. Other witnesses said the airplane sounded as if it were having engine trouble. The airplane came to rest upright with evidence of little forward movement, consistent with the airplane being in a flat attitude at the time of impact. All major components of the airplane were accounted for at the site, and there was no postimpact fire. Photos taken by first responders revealed some airframe icing on the airplane’s left wing, left engine cowling, and nose baggage area. Weather at the time included wind gusts up to 23 kts, with an active AIRMET (Airman Meteorological Information) for icing and a SIGMET (Significant Meteorological Information) for severe turbulence between 3,000 and 16,000 ft msl. A postaccident examination of the airplane and engines revealed no preimpact mechanical deficiency that would have precluded normal operation. Based on the witness’ description of the airplane’s descent and the condition of the wreckage, the airplane entered a spin from which it was not recovered. Since an airplane must first be in a stalled condition before it can spin, either an inadvertent or deliberate stall must have immediately preceded the spin. Further, because a spin entry requires the presence or introduction of a yawing moment at the stall, the NTSB conducted an airplane performance study that considered possible conditions and scenarios that could affect the airplane’s stall performance and produce a yawing moment. These considerations included airframe ice contamination, operation of the engines at different thrust levels (such as during a Vmc demonstration, which is commonly performed during multi-engine airplane instructional flights to demonstrate the airplane’s minimum control airspeed with one engine deliberately shut down or set to minimum thrust), and improper stall recovery technique. The study determined that the 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 the 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 airplane flight manual (AFM). As such, there was no evidence that airframe icing contamination adversely affected the airplane’s stall speed or other aerodynamic characteristics, such as asymmetric stall behavior (one wing stalling before the other). 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 was inconsistent with a scenario involving a Vmc demonstration. The study determined that, at the time of the second stall, the required engine power was reduced compared to the first stall. Given that this second stall occurred less than 30 seconds after the first, the performance study concluded that it was unlikely that the second stall was associated with an attempted Vmc demonstration. 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. FAA guidance for pilots related to spin avoidance in multi-engine airplanes emphasizes initiating stall recovery (reducing the airplane’s angle of attack) as soon as the airplane reaches the stall warning, such as an aural alert or buffet. The guidance references stall practice among the scenarios in which “spin awareness must be at its greatest.” Toxicological testing of the flight instructor identified that he had used multiple central nervous system (CNS) depressants, including medications for anxiety and depression. Although postmortem drug levels do not reliably predict specific impairing effects in this case, the presence of multiple CNS depressants increased the risk of adverse CNS effects, such as increased sedation, decreased alertness, slowed reflexes, and impaired concentration; these effects can potentially occur despite chronic use. The status of the flight instructor’s underlying condition and its response to treatment could not be determined. As pilot-in-command, the flight instructor had ultimate responsibility for the safety of the flight. It is possible that the flight instructor’s judgment may have been adversely affected by his substance use or underlying condition, or both. Also, despite the predictable need to be immediately ready to react to prevent a spin, the experienced flight instructor failed to prevent the spin. The adverse effects of his substance use, the associated underlying condition, or both likely diminished his capacity to act in a timely and appropriate manner, although a more specific determination of the individual contributions of specific medical factors is not possible based on the available evidence.

HISTORY OF FLIGHT 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. PILOT INFORMATION 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. METEOROLOGICAL INFORMATION 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. AIRPLANE INFORMATION 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. WRECKAGE INFORMATION 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