WPR10FA448

A loss of power in the right engine for undetermined reasons and the pilot’s subsequent failure to maintain adequate airspeed, which resulted in a loss of control. Contributing to the loss of control was the regulatory certification basis of the airplane that does not require airspeed indicator markings that are critical to maintaining airplane control with one engine inoperative.

Shortly after takeoff for a repositioning flight for the airplane’s upcoming annual inspection, numerous witnesses, including the two air traffic controllers, reported observing the airplane climbing out normally until it was about 1/2 mile beyond the runway. The witnesses stated that the airplane then underwent a short series of attitude excursions, rolled right, and descended steeply into a lagoon. All radio communications between the airplane and the air traffic controllers were normal. Ground-based radar tracking data indicated that the airplane's climb to about 500 feet was normal and that it was airborne for about 40 seconds. Postaccident examination of the airframe, systems, and engines did not reveal any mechanical failures that would have precluded continued normal operation. Damage to both engines’ propeller blades suggested low or moderate power at the time of impact; however, the right propeller blades exhibited less damage than the left. The propeller damage, witness-observed airplane dynamics, and the airplane’s trajectory were consistent with a loss of power in the right engine and a subsequent loss of control due to airspeed decay below the minimum control speed (referred to as VMC). Although required by the Federal Aviation Administration (FAA)-approved Airplane Flight Manual, no evidence of a cockpit placard to designate the single engine operating speeds, including VMC, was found in the wreckage. The underlying reason for the loss of power in the right engine could not be determined. The airplane's certification basis (Civil Air Regulation [CAR] 3) did not require either a red radial line denoting VMC or a blue radial line denoting the single engine climb speed (VYSE) on the airspeed indicators; no such markings were observed on the airspeed indicators in the wreckage. Those markings were only mandated for airplanes certificated under Federal Aviation Regulation Part 23, which became effective about 3 years after the accident airplane was manufactured. Neither the Federal Aviation Administration (FAA) nor the airplane manufacturer mandated or recommended such VMC or VYSE markings on the airspeed indicators of the accident airplane make and model. In addition, a cursory search did not reveal any such retroactive guidance for any twin-engine airplane models certificated under CAR 3. Follow-up communication from the FAA Small Airplane Directorate stated that the FAA has "not discussed this as a possible retroactive action... Our take from the accident studies is that because of the accident record with light/reciprocating engine twins, the insurance industry has restricted them to a select group of pilot/owners…" Toxicology testing revealed evidence consistent with previous use of marijuana by the pilot; however, it was not possible to determine when that usage occurred or whether the pilot might have been impaired by its use during the accident flight.

HISTORY OF FLIGHT On September 2, 2010, about 1151 Pacific daylight time, a Beechcraft Model 65 Queen Air, serial number LC-112, and registered as N832B, was substantially damaged when it impacted a salt-water lagoon shortly after takeoff from runway 30 at San Carlos Airport (SQL), San Carlos, California. The certificated airline transport pilot, the pilot-rated airplane owner, and the passenger received fatal injuries. The flight was operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, which was destined for South County Airport of Santa Clara County (E16), San Martin, California. According to the local controller in the SQL air traffic control tower (ATCT) who was handling the flight, the pilot requested, and was approved, for the "Bay Meadows" departure. The departure consisted of a climb on runway heading to a point about 3 miles beyond the end of the runway, followed by a left turn, while remaining clear of the overlying Class B airspace for San Francisco International Airport (SFO). The controller reported that the airplane appeared to climb normally, and when it was about 1/2 mile beyond the runway, the controller observed the airplane make a "slight right rudder turn" and then correct back. About 3 to 4 seconds later, the local and ground controllers observed the airplane roll and turn to the right, and descend steeply out of sight. Many other witnesses reported a sequence of events similar to that observed by the controllers, but a few reported that the pitch excursion began before the roll excursion. All agreed that the airplane banked sharply to the right, followed closely by the nose pointing towards the ground. None reported a spin, and an ex-airline pilot was certain that the airplane did not spin. No radio transmissions regarding the event were received from the airplane. Ground-based radar tracking data indicated that the airplane reached a maximum altitude of 500 feet, and that the airplane was airborne for about 40 seconds. Witnesses who saw the impact all reported that the airplane descended at a steep angle, in a nose-down attitude. The airplane struck the water in the shallow lagoon, and sank within a few minutes. First responders recovered the passenger shortly after the accident. The airplane was recovered from the lagoon about 30 hours after the accident. PERSONNEL INFORMATION Front Left Seat Occupant According to FAA records, the individual in the front left seat held an airline transport pilot certificate, as well as flight and ground instructor certificates. He was 72 years old, and his most recent FAA second-class medical certificate was issued in April 2010. At the time of that application, he reported 18,000 total hours of civilian flight experience. A "Pilot History Form" for that individual, which contained hand-written entries and his signature, was recovered from the wreckage. That form was dated September 2009, and was part of an airplane insurance application/information package for the accident airplane and the registered owner. The form listed the individual's occupation as "aviator," and the date of his most recent flight review as January, 2008. He reported his total hours "Flying Hours as Pilot-in-Command" as "18k+," including "6k+" in the accident airplane make and model, and 150 hours in the 90 days prior to that application. According to persons who either knew him or the airplane owner, the front left seat occupant was an aviation acquaintance of the owner. The owner's son stated that to his knowledge, that individual was the only person who flew the accident airplane in recent years. This individual was in the left front seat when the airplane was recovered from the lagoon. The San Mateo County Coroner's Office autopsy report stated "multiple blunt injuries" as the cause of death. The Coroner's report on forensic toxicology examinations on specimens stated "No common acidic, neutral or basic drugs detected" and "No blood Ethyl Alcohol detected." The report stated that blood carboxyhemoglobin saturation was less than 3 percent. A subsequent separate communication from the Coroner's Office explicitly stated that "our normal toxicology screen does not test for THC." THC is the abbreviation for tetrahydrocannabinol. The FAA Civil Aeromedical Institute (CAMI) also conducted forensic toxicology examinations on specimens from the individual in the front left seat. The carboxyhemoglobin test, which used a cutoff saturation limit of 10 percent, indicated that no carbon monoxide was detected in the blood. Tetrahydrocannabinol was detected in the lung, liver and chest cavity blood samples, and tetrahydrocannabinol carboxylic acid was detected in the lung, liver, chest cavity blood, and urine samples. The son of the individual stated that he did not have any direct knowledge of his father's use of marijuana. Front Right Seat Occupant The individual in the front right seat was the registered owner of the airplane. He was 91 years old. According to FAA records, he held a commercial pilot certificate, with airplane single engine and multi-engine land ratings. On his April 2004 application for an FAA medical certificate, which was denied, he reported 12,004 total hours of civilian flight experience. No records of any subsequent FAA medical applications were discovered, and he did not hold a valid FAA medical certificate at the time of the accident. The San Mateo County Coroner's Office autopsy report stated "multiple blunt injuries" as the cause of death. The Coroner's report on forensic toxicology examinations on specimens stated "No common acidic, neutral or basic drugs detected" and "No blood Ethyl Alcohol detected." The report stated that blood carboxyhemoglobin saturation was less than 3 percent. The FAA CAMI also conducted forensic toxicology examinations on specimens from the individual in the front right seat. The carboxyhemoglobin test, which used a cutoff saturation limit of 10 percent, indicated that no carbon monoxide was detected in the blood sample. Ethanol was detected in the brain and blood samples, methanol was detected in the muscle and blood samples, and N-Propanol was detected in the brain sample. Amlodipine, which is used alone or in combination with other medications to treat high blood pressure and chest pain (angina), was detected in the liver and blood samples. Passenger The female passenger was 47 years old, and did not hold any pilot certificates. She was recovered from the lagoon shortly after the accident, and the investigation was unable to determine where she was seated for the flight. The San Mateo County Coroner's Office autopsy report stated "multiple blunt injuries" as the cause of death. The Coroner's report on forensic toxicology examinations on specimens stated "No common acidic, neutral or basic drugs detected" and "No blood Ethyl Alcohol detected." The report stated that blood carboxyhemoglobin saturation was less than 3 percent. According to one of her sons, she was in a personal relationship with the front left seat occupant, and that she did not use marijuana. AIRCRAFT INFORMATION History and Background Information According to FAA records, the airplane was manufactured in 1961, and was equipped with two Lycoming IGSO-480 piston engines. Each engine was equipped with a three-blade fully feathering Hartzell propeller, controlled by a lever in the cockpit. The airplane was equipped with tricycle-configuration retractable landing gear. The airplane was certificated to carry 9 persons, including 2 crewmembers, and had a maximum takeoff weight of 7,700 pounds. Entry and exit was via a cabin door aft of the left wing. At the time of the accident, the airplane was registered to an individual who had purchased it in August 2008. Airport administrative records indicated that the air