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Accidents · NTSB WPR09FA309 · Final report

Beech B95 accident near Holbrook, Arizona, June 25, 2009

On June 25, 2009, a Beech B95, registered N912T, was substantially damaged in an accident during initial climb near Holbrook, Arizona (Holbrook Municipal airport). It was a personal flight under general aviation rules (Part 91). 4 people were killed. The weather was visual conditions (good weather).

The NTSB's probable cause their words, unchanged

The pilot’s decision to depart when ill and his failure to maintain control of the airplane during a return to the airport, likely because of his physical illness and drug impairment.

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

What the record shows

Date
June 25, 2009
Place
Holbrook, Arizona · Holbrook Municipal · map
Type
Accident
Injuries
4 people were killed.
Weather
visual conditions (good weather)
Aircraft
Beech B95 · all B95s on the register
Registration
N912T · registry record · serial TD-364
Damage
Substantial damage
Flight
Personal flight · general aviation rules (Part 91)

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

After landing, the pilot told witnesses that he vomited en route to the airport. After fueling, he went into the airport lounge, and laid down on a sofa in a fetal position. The witnesses stated that he looked ill, referring to him as clammy or pale. After the passengers returned from lunch, they boarded the airplane. A professional pilot saw the airplane depart in a direction such that the wind varied from a quartering tailwind to a direct crosswind at 5 to 10 knots. The airplane climbed about 300 feet, made a 45-degree right turn, then entered a left turn, and appeared to be returning to runway 21. As the airplane rolled through the extended centerline of the runway, the bank angle increased until the left wingtip was pointed at the ground. The airplane continued to roll until the nose was pointed toward the ground before impact. Examination of the wreckage revealed no mechanical anomalies with the airframe or engine. It was very likely that the acute gastrointestinal distress the pilot was suffering at the time impaired his ability to successfully fly the airplane. Due to his condition, the pilot likely decided to return to the departure airport, but failed to maintain control of the airplane. The pilot’s toxicology report revealed distant use of propoxyphene, a pain medication. No personal medical records were found, so it was not possible to determine of the effect of the underlying painful condition. However, the distant use of the medication was unlikely to have impaired the pilot or caused his gastric distress at the time. Phentermine was also identified in the toxicology report; this medication carries an FDA warning “may impair the ability of the patient to engage in potentially hazardous activities such as operating machinery or driving a motor vehicle.” The use of phentermine may have further impaired the pilot’s ability to safely fly the airplane, and may have played a role in his willingness to attempt a flight while suffering from nausea and vomiting.

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 defining event
  2. Collision with terrain or object (not controlled flight into terrain) during uncontrolled descent

The NTSB's findings

  • cause Aircraft › Aircraft oper/perf/capability › Performance/control parameters › (general) › Not attained/maintained
  • cause Personnel issues › Action/decision › Info processing/decision › Decision making/judgment › Pilot
  • cause Personnel issues › Physical › Impairment/incapacitation › Illness/injury › Pilot
  • cause Personnel issues › Physical › Impairment/incapacitation › Prescription medication › Pilot
  • cause Personnel issues › Physical › Health/Fitness › Use of medication/drugs › Pilot

Pilot

  • Certificate: flight instructor, commercial pilot
  • Ratings: multi-engine land; single-engine land; instructor: airplane multi-engine; instructor: airplane single-engine; instructor: instrument airplane; instrument: airplane
  • Flight time: 4,200 hours in all; 300 in this make and model
  • Medical certificate: Class 1 (without waivers/limitations)
  • Seat: left
  • Injury: fatal

The aircraft

  • Last inspection: annual inspection
  • Seats: 5
  • Landing gear: retractable
  • Engine 1: Lycoming O-360-A1A (piston); 0 hours total
  • Engine 2: Lycoming O-360-A1A (piston); 0 hours total
  • Fire on the ground

The flight

  • Departed from: P14 Holbrook AZ at 11:59 pm
  • Destination: Largo Vista TX
  • Flight plan: none
  • Runway 03, 6,698 ft by 75 ft

Weather at the time

  • Light: daylight
  • Wind: from 260° at 13 knots
  • Visibility: 10 statute miles
  • Sky: clear
  • Temperature: 91°F (33°C), dew point 39°F (4°C)
  • Altimeter: 30.03 inHg
  • Observation at 10:56 pm from INW, 29 miles away

Injuries

FatalSeriousMinorNone
Flight crew1
Passengers3

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

The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), has not been read from the NTSB for this case yet; the list appears here once it has. Open the docket at the NTSB.

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.