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Accidents · NTSB ERA20FA022 · Final report

Beech 58 accident near Ocala, Florida, October 31, 2019

On October 31, 2019 at about 3:31 pm local time, a 1996 Beech 58, registered N959CM, was destroyed in an accident during initial climb near Ocala, Florida (Ocala Intl-Jim Taylor Field). It was a flight test under general aviation rules (Part 91). 2 people were killed. The weather was visual conditions (good weather).

The NTSB's probable cause their words, unchanged

The pilot’s failure to maintain control of the airplane due to an acute medical event and/or his use of impairing medications.

Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.

What the record shows

Date
October 31, 2019 · about 3:31 pm local time
Place
Ocala, Florida · Ocala Intl-Jim Taylor Field · map
Type
Accident
Injuries
2 people were killed.
Weather
visual conditions (good weather)
Aircraft
Beech 58 Undesignat, built 1996 · all 58s on the register
Registration
N959CM · no longer on the register · serial TH-1792
Damage
Destroyed
Flight
Flight test · general aviation rules (Part 91)

The NTSB's narrative final · quoted from the NTSB record

After experiencing an issue with a fluctuating fuel transducer on the right engine, the pilot hired a mechanic, who removed the fuel flow transducers from both engines and reinstalled them on the opposite engine to determine if there was an instrument indication problem or a fuel flow sensor issue. After performing the maintenance, the pilot and mechanic performed several ground runs of the engines without incident. They then departed on a local flight. Review of air traffic control communications revealed that the pilot initially taxied to the wrong runway, and after takeoff, failed to acknowledge multiple calls from the controller, did not follow the controller’s instructions, and thought that he was flying west when he was flying toward the east. About 2 minutes after takeoff, a transmission was received from the accident airplane requesting to return to the airport. The airplane impacted a four-lane divided highway and was consumed by a postcrash fire. Examination of the airplane, both engines, and their respective fuel transducers revealed no mechanical discrepancies that would have precluded normal operation. Autopsy of the pilot revealed severe abdominal aortic atherosclerotic disease, which increased his risk for an extra-cardiovascular event such as a stroke. Toxicology testing detected the impairing medication diazepam and its metabolite at the lower end of its therapeutic range in the pilot’s chest blood. Toxicology testing also revealed that the primary psychoactive compound of marijuana, THC, was detected in the pilot’s blood just above the laboratory’s detection limit. The THC concentration did not suggest recent use and it is unlikely that the pilot’s use of marijuana contributed to the accident. The circumstances of the accident indicate that the pilot did not perform in a manner consistent with his level of skill and experience, and it is likely that his loss of control was the result of physiological impairment; however, whether his impairment was the result of an acute medical event and/or his use of impairing medications could not be determined based on the available information.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

The factual record from the NTSB's investigation tables, in plain English

What happened, in order

  1. Loss of control in flight during initial climb
  2. Aerodynamic stall/spin during initial climb
  3. Medical event during initial climb defining event

The NTSB's findings

  • Personnel issues › Action/decision › Info processing/decision › Identification/recognition › Pilot
  • Personnel issues › Physical › Impairment/incapacitation › (general) › Pilot
  • Aircraft › Aircraft oper/perf/capability › Performance/control parameters › (general) › Not attained/maintained
  • Personnel issues › Task performance › Use of equip/info › Aircraft control › Pilot

Pilot

  • Certificate: private
  • Ratings: multi-engine land; single-engine land; single-engine sea; instrument: airplane
  • Flight time: 7,800 hours in all
  • Last flight review: October 4, 2019
  • Medical certificate: Class 3 (with waivers/limitations)
  • Seat: left
  • Injury: fatal

Passenger

  • Seat: rgt
  • Injury: fatal

The aircraft

  • Airframe total time: 1,979 hours
  • Last inspection: annual inspection, March 18, 2019; 61 hours since
  • Maximum gross weight: 5,500 lb
  • Seats: 6
  • Landing gear: retractable
  • Engine 1: Continental IO-550-C31B (piston); 1,979 hours total
  • Engine 2: Continental IO-550-C31B (piston); 1,979 hours total
  • Fire on the ground
  • Operator: Caribbean World Resorts Ltd

The flight

  • Departed from: OCF Ocala FL at 3:28 pm
  • Destination: OCF Ocala FL
  • Flight plan: none
  • Runway 18, 7,467 ft by 150 ft

Weather at the time

  • Light: daylight
  • Wind: from 200° at 7 knots
  • Visibility: 10 statute miles
  • Sky: a few clouds at 2,200 ft
  • Temperature: 84°F (29°C), dew point 75°F (24°C)
  • Altimeter: 30.05 inHg
  • Observation at 3:40 pm from OCF, 2 miles away

Injuries

FatalSeriousMinorNone
Flight crew1
Passengers1

Documents from the investigation the NTSB's docket: the evidence folder behind the report

18 documents, released by the NTSB on November 16, 2021. View them here, or download them; the NTSB redacts some personal details before release, and this site shows the NTSB's own titles rather than its file names.

The same docket at the NTSB · documents without a copy here are fetched from the NTSB when you open them.

Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.