Aircraft Accident A Result Of Carbon Monoxide Poisoning
On December 17,
2000, at 1821 Central Standard Time, a Beech BE-23, N2324J, was
destroyed when it impacted hilly, wooded terrain near
A witness reported
the pilot flew from
A witness reported the accident pilot inspected N2324J's airframe and engine logbooks. During the airplane inspection, the pilot expressed concern about the welds on the ends of the muffler shroud. The accident pilot completed the pre-buy inspection of N2324J.
The owner of
N2324J reported the accident pilot arrived at 1430. He reported the
accident pilot inspected the airplane while it was in the hangar and
completed the pre-buy inspection by 1500. He reported all three pilots
went to lunch before departing. He reported N2324J was taxied to the Jet
Corp ramp where it was topped off with 40 gallons of fuel prior to
The owner of N2324J reported the accident pilot arrived at 1430. He reported the accident pilot inspected the airplane while it was in the hangar and completed the pre-buy inspection by 1500. He reported all three pilots went to lunch before departing. He reported N2324J was taxied to the Jet Corp ramp where it was topped off with 40 gallons of fuel prior to departing.
The pilots in the Cessna 182 reported the accident pilot departed in
N2324J about 1700. They departed in the Cessna 182 about 5-7 minutes
later. They were not able to make radio contact with N2324J once they
departed. One of the pilots reported that they knew they would out run
N2324J since their ground speed was about 90 kts, and N2324J's ground
speed was about 65-70 kts due to a 35 kts headwind. The Cessna 182
The radar data indicated the airplane's altitude remained between 8,700 and 8,500 feet mean sea level (msl) from the period between 1800:25 and 1808:52, but the airplane's heading was inconstant, first heading to the northwest, then heading to west and then to the south, and making a 360 degree turn before heading south again. The radar data indicated the airplane's altitude started descending from 8,500 feet msl at 1809:04 to an altitude of 2,000 feet msl recorded at 1821:08, which was the last radar return recorded. Between 1809:04 and 1821:08, the radar data indicated the airplane's flight path was a series of inconstant descending turns that took the airplane in an easterly direction. The last radar return was approximately .5 nautical mile from the accident site.
A witness reported
that on December 17, 2000, at 1830, a, "Plane or aircraft made a low
pass over my house from the north and back to the north close to the
house. I was watching T.V. I told my wife who is that crazy person
flying that plane? I went out on the front porch and watched the
aircraft make two short clock wise turns to the east of my house very
low to the ground. Then I went to the back porch of my house and watched
the plane go to the east. It made a steady climb over the timberline,
and a sudden descent out of sight. I came back in the house and told my
wife I think that the plane went down." The witness reported the
incident to the highway patrol.
A search for
N2324J was initiated on December 18, 2000. The airplane was located in a
heavily wooded ravine near
The pilot held a
commercial pilot certificate with single-engine land and multi-engine
land, and instrument ratings. He held a certified flight instructor
certificate with privileges to instruct in single engine land and
multi-engine land airplanes. He held a Second Class medical certificate.
The pilot had a total of about 2,426 hours of flight time as of May 1,
2000. The pilot's flight logbooks were not recovered.
The airplane was a
single engine Beech BE-23, serial number M275. The airplane seated four
and had a maximum gross weight of 2,300 pounds. The engine was a 160
horsepower Lycoming O-320-D3B engine. The last annual inspection was
conducted on August 16, 2000. The airplane had flown 6 hours since the
last inspection and had a total time of 2,082 hours.
The previous owner
of the airplane reported he had numerous repairs made to the airplane
during the annual inspection in May 1999. The aircraft logbooks
indicated the airplane flew 17.1 hours between the 1999 annual
inspection and the 2000 annual inspection. The pilot reported he flew
the airplane about 6 hours since the annual inspection in August 2000.
He reported he had not flown the airplane in cold weather since the
logbooks indicated the muffler was inspected in accordance with
Airworthiness Directive (AD) 64-06-01 on May 21, 1999, during the annual
inspection. Maintenance records indicated the muffler was replaced on
November 26, 1973. The maintenance records indicated the cabin heater
and muffler weld assembly had been "checked for leaks and deteriation"
during the 1999 annual inspection, and they were found to be "OK."
The 1753 weather
observation at the Rolla/Vichy Regional Airport (VIH),
The pilot of the
Cessna reported the headwind at 8,500 feet was approximately 35 knots.
impacted the ground in a steep nose down attitude on a heading of 280
degrees magnetic. There was little damage to the surrounding trees. The
propeller and engine were buried in the ground with the back of the
engine being about 6 inches below ground level. The cabin, fuselage,
left and right wings, and empennage remained attached and were found
crushed and buckled at the impact site. The leading edges of the left
and right wings exhibited leading edge crush. The pilot's seatbelt was
was confirmed to the flight controls.
blades exhibited "S" bending, leading edge gouges and chordwise
scratching. Broken tree branches and limbs were found that exhibited
propeller slashes and gray paint transfer.
and thumb compression could not be obtained because the crankshaft was
bent approximately five degrees up and towards the number two cylinder.
The left magneto was tested and produced spark at all distribution
points. The right magneto could not be tested due to impact damage. The
carburetor was broken from its mounting. The fuel pump could not be
tested due to impact damage, but a trace amount of fuel was found. The
spark plugs condition was consistent with normal operation.
assembly was found crushed and laying on top of the engine at the
wreckage site. It was removed and sent to the National Transportation
Safety Board (NTSB) for metallurgical examination.
An autopsy was
performed on the pilot on December 23, 2000, at the Boone/Callaway
County Medical Examiner's Office.
Toxicology Fatal Accident Report was prepared by the FAA Civil
Aeromedical Institute. The report concerning the pilot indicated the
detected in the kidney or liver.
No drugs detected.
monoxide test could not be performed due to an inadequate blood sample.
TESTS AND RESEARCH
The NTSB Materials
Laboratory Factual Report stated the muffler and heater muff assembly
contained severe crushing deformation and was fractured into two pieces.
A microscopic examination of the muffler portion revealed the internal
wall exhibited oxidation damage. The report stated, "Many areas of the
muffler fracture showed oxidation damage that penetrated through the
wall. The oxidation damage areas on the fracture appeared black,
consistent with a pre-existing fracture that was exposed to the
environment for an extended period of time." It further stated, "By
visual estimate, the total combined length of the oxidation damage areas
that penetrated through the wall was at least 20% of the circumference
of the body of the muffler.
The NTSB report
stated, "The examination of the fractures from the heat exchanger
collector tube showed evidence of minor tinting which is consistent with
short-term (post crash) exposure to heat." It stated, "The outer layer
of the tube had a decaburized layer, typical of steel exposed to high
temperature and the environment for an extended period of time. The
fracture surface of the heater muff exhibited no evidence of tinting."
The NTSB report
stated the welds at the muffler end caps were intact and showed no
cracks. (See Materials Laboratory Factual Report)
The FAA issued an
Aircraft Circular (AC) bulletin, "AC 20-32B, Carbon Monoxide (CO)
Contamination in Aircraft-Detection and Prevention," on November 24,
1972. The AC stated, "Many light aircraft cabins are warmed by air that
has been circulated around the engine exhaust pipes. A defect in the
exhaust pipes or cabin heating system may allow carbon monoxide to enter
the cockpit or cabin. The danger is greatest during the winter months
and any time the temperature is such that use of the cabin heating
system becomes necessary and windows and vents are closed."
Parties to the
investigation included the Federal Aviation Administration, the Raytheon
Aircraft Company, and Textron Lycoming.
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