ATL03FA002
ATL03FA002

HISTORY OF FLIGHT

On October 9, 2002, about 1057 eastern daylight time, a Beech K35, N5350E, registered to a private owner, operating as a 14 CFR Part 91 personal flight, broke up in flight after the pilot became incapacitated in the vicinity of Jellico, Tennessee, on Pine Mountain. Marginal visual meteorological conditions prevailed in the vicinity of the accident site, and an instrument flight rules flight plan was filed. The airplane was destroyed. The private pilot was fatally injured. The flight originated from Houghton Lake, Michigan, on October 9, 2002, at 0802.

Review of transcripts between the pilot and Indianapolis Center revealed the pilot had requested and received weather for Atlanta, Georgia, and Knoxville, Tennessee. Indianapolis Center started coordinating a hand-off of the flight with Atlanta Center at 1048:36. Indianapolis Center instructed the pilot to contact Atlanta Center at 1056:03. The pilot did not respond to the request. Indianapolis Center instructed the pilot to contact Atlanta Center again at 1056:13, and to verify that he was level at 9,000 feet. The pilot did not respond to the request. The last radar return observed by Indianapolis Center was at 1056:10, and the mode C read out showed the airplane was at 7,700 feet.

At 1055 and 1106, the Campbell County 911 operator located in La Follette, Tennessee, stated he received two phone calls from separate local residents stating that they had heard an airplane fly over their location followed by what sounded like a "plane going down." A Sheriff Deputy was dispatched and pieces of the airplane wreckage were located at 1235, in the vicinity of Pine Mountain.

PERSONNEL INFORMATION

Review of information on file with the FAA Airman's Certification Division, Oklahoma City, Oklahoma, revealed the pilot was issued a private pilot certificate on November 10, 1976, with ratings for airplane single engine land, multiengine land, and instrument airplane. Review of the pilot's logbook revealed his last recorded flight and biennial flight review was conducted on March 1, 2002. A handwritten paper log sheet found in the logbook revealed the pilot had flown 16 additional flights between March 8, 2002, to July 7, 2002. Review of records on file with the FAA Aeromedical Certification Division revealed the pilot held a third class medical certificate issued on May 22, 2001. The pilot reported he had accumulated 6,000 total hours with 50 hours flown in the last six months.

The pilot underwent coronary artery bypass surgery on January 17, 2002. There is no record that the pilot informed the FAA of a change in his medical condition. The pilot reported that he had accumulated 6,700 total hours with no hours flown in the last 6 months and noted "yes" for item 18.g. "Heart or vascular trouble.". The Aviation Medical Examiner who conducted the physical examination noted the pilot's history of coronary artery bypass surgery and reported on the application, " No certificate issued-Deferred for further evaluation."

AIRCRAFT INFORMATION

Review of aircraft maintenance records revealed the last recorded annual inspection was completed on April 11,2002, at 144.1 hours. The airplane had accumulated 23.5 hours since the annual inspection. The engine was rebuilt by Teledyne Continental Motors on September 28, 1999, and was installed on October 28, 1999. The engine had accumulated 167.7 hours since installation. The propeller was manufactured by McCauley Propellers on September 30, 1999, and installed on October 28, 1999. A new zero time tachometer was installed on October 28, 1999. The old tachometer showed 2,830.0 hours at replacement. The tachometer at the crash site showed 167.7 hours. The altimeter test was conducted on June 6, 2002. The transponder and pitot static system test was completed on June 7, 2002. The ELT battery was due replacement on May 31, 2002.

Review of refueling records on file at Blodgett Aviation, Houghton Lake, Michigan, revealed the airplane was topped off with 29.7 gallons of aviation 100 low lead fuel on October 7, 2002.

METEOROLOGICAL INFORMATION

The nearest weather reporting facility at the time of the accident was Oak Ridge, Tennessee. The 1053 surface weather observation was: 2,100 broken, 4,600 overcast, visibility 7 miles, temperature 64 degrees Fahrenheit, dew point temperature 59 degrees Fahrenheit, wind calm, and altimeter 30.21" Hg. The National Weather Service Depiction Chart for 1100 depicted marginal visual flight rules conditions in the immediate vicinity of the accident site, with ceilings overcast from 1,300 to 1,600 feet.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located on the side of Pine Mountain south of No Business Road. The crash site was about 2 3/4 miles southeast of Jellico, Tennessee, and about 36 miles north northwest of Knoxville Downtown Airport, Knoxville, Tennessee. The average height of the terrain in the vicinity of the crash site was 1,600 feet and the crash debris line was on a heading of 050 degrees magnetic starting south of No Business Road.

The rear fuselage containing the empennage attachments and controls was located south of No Business Road. The left stabilizer was located 800 feet to the left of the crash debris line adjacent to the empennage. The airplane logbooks were located 48 feet down and on the crash debris line. The outboard section of the right outboard wing was located 240 feet left of the crash debris line adjacent to the logbooks. The separated left wing was located 170 feet down the crash debris line and 94 feet left of the crash debris line. The inboard section of the right wing attached to the carry through assembly was located 200 feet down the crash debris line and 75 feet right of the crash debris line. The right stabilizer was located 240 feet down the crash debris line and 240 feet left of the crash debris line. A section of the left cabin sidewall containing the third window was located 245 feet down the crash debris line and 145 feet left of the crash debris line. The left elevator trim tab was located 270 feet down the crash debris line and 565 feet left of the crash debris line. The cabin door was located 350 feet down the crash debris line and 210 feet left of the crash debris line. A section of the left wing leading edge containing the stall-warning vane was located adjacent to the cabin door and 330 feet left of the crash debris line. The pilot was located 460 feet down the crash debris line and 375 feet right of the crash debris line. A section of the cabin roof containing an air scoop and the top of the rear baggage upper wall was located 560 feet down the crash debris line and 370 feet left of the crash debris line. The engine assembly and cabin walls were located 725 feet down and on the crash debris line. Rear fuselage pieces were located 750 feet down the crash debris line and 67 feet and 300 feet left of the crash debris line. The inboard piece of the right elevator was located 800 feet down the crash debris line and 460 feet left of the crash debris line. The outboard piece of the left elevator was located 850 feet down the crash debris line and 500 feet left of the crash debris line.

The engine assembly was displaced to the right and buried inverted in the ground about two feet. The propeller assembly was attached to the crankshaft flange. The engine assembly was attached to the nose assembly. The upper engine cowlings were found in close proximity to the wreckage. The nose gear was in the retracted position. There was evidence of a post crash fire on the cabin side firewall insulation and in the vicinity of the right rudder bell crank. There was no evidence of a post crash fire in the vicinity of the left rudder bell crank.

The left and right windshields were broken out, and there was no evidence of soot on the windscreen frame on the cabin side or externally. The instrument panel remained attached to the firewall. There was no sooting exhibited externally on the radios and no sooting was present on the left sub panel switches. The cabin floor remained attached to the firewall by flight control cables. The cabin floor separated from the front carry through. The front seats and the right rear seat remained attached to the cabin floor between the front and rear carry through. The cabin sidewalls and roof separated from the cabin floor. The cabin door and the front part of the doorframe separated from the nose assembly. There was no evidence of soot on the interior cabin door and fabric. There was no evidence of soot on the nose section skin. The cabin interior fabric on the forward edge of the front carry through and the pilot's fresh air vent exhibited no evidence of soot. There was no evidence of soot on the pilot and passenger seat. The pilot's seat belt and shoulder harness were found unfastened.

The right wing remained attached to the front and rear carry through. The front spar and leading edge of the right wing separated three feet outboard of the wing root. The right wing panel separated four4 feet eight inches outboard of the wing root. The right aileron separated from the wing and was not recovered. Aileron flight control continuity in the wing was confirmed to the aileron bellcrank.The right flap remained attached to the wing and was in the retracted position. The main fuel tank, auxiliary fuel tank, and wing tip fuel tank were ruptured. The front top spar cap was deformed downward. The piano hinge wire was pulled out of the top spar cap on the wing panel side. The bottom spar cap exhibited compression buckling on the separated outboard section of the right wing. The bottom spar cap on the inboard section of the right wing was deformed downward and the two piano hinge wires were separated. The right main landing gear was in the retracted position.

The rear fuselage sidewall separated eight feet six inches aft of the firewall and extended aft 13 feet 6 inches. The bulkhead assembly, station 256.9 and bulkhead assembly 272.0 were intact with no evidence of cracking. There was no evidence of soot trailing along the fuselage sidewalls or empennage. The right stabilizer front spar separated at the first set of attaching bolts. The separated stabilizer front spar remained bolted to bulkhead assembly station 256.9. The rear stabilizer spar separated at the first set of attaching bolts. The separated section of the stabilizer rear spar remained bolted to bulkhead assembly station 272.0.The right stabilizer cuff bottom edge was flared downward. The right elevator trim tab cables cut the fuselage downward out of the pass through hole. The right stabilizer front spar tore the fuselage skin downward.

The right stabilizer leading edge exhibited compression buckling 6-inches outboard of the stabilizer root rib. The top of the right stabilizer exhibited diagonal compression buckling 34-inches outboard of the stabilizer root. The right elevator separated into multiple pieces. The inboard 15-inches of the right elevator with the attached control horn was recovered. The inboard elevator bearing was pulled out of the elevator casting. The control stops were not deformed. The right elevator control rod separated at the elevator control horn rod end. The elevator control rod end remained attached to the elevator control horn. The right elevator trim tab hinge was pulled out of the trailing edge of the elevator.

The left stabilizer cuff bottom edge was flared downward. The left elevator trim tabs cables cut the fuselage downward out of the pass through hole. The left stabilizer front spar tore the fuselage skin downward. The left stabilizer leading edge exhibited compression buckling 1 feet 3 inches outboard of the stabilizer root rib. The top of the stabilizer exhibited diagonal compression buckling 3 feet outboard of the stabilizer root rib extending outboard 3 feet 10 inches. The inboard 15-inches of the left elevator was separated from the root rib. The left elevator root rib remained connected to the airplane. The elevator push rod remained intact. The elevator control stops were not deformed. The left elevator trim tab was recovered. The hinge line was intact and was separated from the elevator. A section of the left elevator leading edge located between the elevator trim pass through and the first elevator hinge was recovered. The outboard section of the elevator was recovered. The elevator counter balance assembly was separated from the elevator.

The left wing front carry through upper wing attach bolt was separated. The lower front wing attachment fitting separated from the front carry through, and it remained attached to the wing. The rear wing attach fittings separated from the carry through and remained attached to the wing. The left wing was deformed downward 6 feet 8 inches outboard of the wing root. The inboard 7 feet of the leading edge of the left wing was crushed inward. A 3-foot section of the leading edge of the wing separated from the middle section of the wing. The remainder of the leading edge of the wing remained attached to the wing and was crushed inward and upward. The main fuel tank, auxiliary fuel tank and wing tip fuel tank were ruptured. Aileron flight control continuity was confirmed to the aileron bellcrank.The aileron remained attached to the wing. The flap remained attached to the wing and was in the retracted position. The landing gear extend rod separated from the landing gear actuator and the landing gear was extended.

Elevator flight control continuity was established from the control column to the differential controller. Rudder flight control continuity was established from the cockpit to the differential controller. Flight control continuity between the differential controller and the elevators was confirmed.

The engine assembly sustained fire and impact damage to the aft end of the engine and accessories. The fuel pump drive coupling was separated. The crankcase magneto mounting pads were separated from the crankcase. The fuel manifold valve and fuel injector lines sustained impact damage. Residual fuel was present in the fuel injector lines. The engine sump was crushed inward. The engine was rotated by hand and valve and drive train continuity was confirmed. A thumb compression check was performed and compression and suction was confirmed on all cylinders except for cylinder No.1. The compression was escaping through the exhaust valve where debris entered through a broken valve cover.

The vacuum pump sustained impact and fire damage. The data plate was destroyed and the drive coupling was consumed by fire. The vanes and rotor sustained fire and impact damage. The case and end plate exhibited normal wear.

The airspeed indicator and encoding altimeter were destroyed. The vertical speed indicator indicated up 1,325 feet per minute.

Examination of the electric turn and bank indicator revealed the case was damaged. The factory seal was not located, and the data plate was present The bezel was not damaged and the bezel glass was not broken. Disassembly of the turn and bank coordinator revealed the pivot point had not separated from the rotor assembly, and scoring was present on the rotor.

Examination of the directional gyro revealed the case was damaged and the data plate was installed. A factory seal was not installed. The bezel sustained impact damage and the bezel glass was broken. The heading and push knob was bent. Disassembly of the directional gyro revealed the pivot point had separated from one side of the rotor assembly and the yoke assembly was broken. Slight scoring was present on the rotor.

Examination of the horizon gyro revealed the case was damaged and the data plate was present. The factory seal was not present. The bezel was not damaged, but the bezel glass was broken. Disassembly of the attitude gyro revealed the yoke assembly was broken and slight scoring was present on the rotor. No scoring was present on the surface of the rotor housing.

MEDICAL AND PATHOLOGICAL INFORMATION

Review of pilot's medical records revealed coronary artery bypass surgery was conducted on January 17, 2002, for severe multi vessel coronary artery disease. The pilot underwent a stress thallium test on July 22, 2002. The report of stress thallium test, found in the pilot's cardiologists records revealed a combination of small antero-apical infarction, mild to moderate intensity ischemia in the peri-infarct antero-apical and apical anterior septum, and preserved left ventricular systolic function. The stress thallium test report was not found in the FAA medical records associated with the pilot's last application for a medical certificate. A stress echocardiogram was conducted on August 1, 2002, and was reported as normal. The stress echocardiogram report was found in the FAA medical records associated with the pilot's last application for a medical certificate.

The University of Tennessee Medical Center, Knoxville, Tennessee, Forensic Pathologist, Medical Examiners Office, conducted a postmortem examination of the pilot on October 12, 2002. The cause of death was multiple blunt force trauma. In addition to multiple injuries, the significant findings include atherosclerotic cardiovascular disease consisting of:
a. Atherosclerosis of native coronary arteries, moderate to focally severe, including post anastomotic segments.
b. Status post coronary artery bypass surgery, remote, multiple, with occlusion of ostium for graft supplying left anterior descending coronary artery.

Postmortem toxicology of specimens from the pilot was performed by the Forensic Toxicology Research Section, Federal Aviation Administration, Oklahoma City, Oklahoma. The results were negative for carbon monoxide, cyanide, ethanol, and basic and acidic drugs.

TEST AND RESEARCH

Review of radar data from Knoxville Approach and Atlanta Center revealed the airplane was at 8,900 feet at 1054:40 heading southbound. At 1055:40, the airplane was in a right turn at 8,600 feet. At 1055:52, the airplane was at 9,000 feet heading towards the north-northeast. The airplane was last observed on radar at 1056:10.

Components from the left and right wing, left and right stabilizer, and the aft portion of the fuselage were forwarded to the NTSB Materials Laboratory for further analysis. All fractures examined by the NTSB Materials Laboratory were typical of overstress separations. There was no evidence of fatigue cracking or other type of preexisting defect.

ADDITIONAL INFORMATION

The wreckage was released to Atlanta Air Recovery on October 23, 2002. The pilot's logbooks were released to the wife of the deceased pilot on October 24, 2002. The components forwarded to the NTSB Material Laboratory for further analysis were released to Atlanta Air Recovery on March 23, 2003.










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