NTSB CAROL · Event
Event DEN90FA184
Registry · N23ST
FAA Aircraft Registry record.
Make / Model
BEECH 200
Year of manufacture
1978 · 12 years old at event
Engine
P&W CANADA PT6A-60A (1050 hp)
Seats / Engines
11 seats · 2 engines
Last airworthiness date
19780524
ADS-B equipped
Yes — Mode-S A207C9
Registrant of record
GREENSKY AVIATION LLC
Source: FAA Aircraft Registry (releasable master file).
Aircraft involved
Probable cause & findings
FAILURE OF THE PILOT TO MAINTAIN A CLIMB AFTER TAKEOFF, DUE TO SPATIAL DISORIENTATION. FACTORS RELATED TO THE ACCIDENT WERE: DARKNESS, PILOT FATIGUE, AND THE PILOT'S LACK OF RECENT EXPERIENCE IN NIGHT FLYING OPERATION.
Factual narrative
THE PILOT, A HEART TRANSPLANT SURGEON, WAS ADVISED OF A DONOR IN LAS CRUCES, NM. HE AND A PHYSICIAN'S ASSISTANT WERE TO FLY TO LAS CRUCES, RETRIEVE THE DONOR HEART, AND RETURN TO ALBUQUERQUE, WHERE THE TRANSPLANT WAS TO BE PERFORMED. THE PILOT OBTAINED A WEATHER BRIEFING (VMC WAS FORECAST) AND FILED AN IFR FLIGHT PLAN. HE FUELED THE JET AIRCRAFT TO CAPACITY AND TOOK OFF INTO A DARK, CLEAR, MOONLESS NIGHT TOWARDS OPEN, FLAT TERRAIN WITH FEW GROUND LIGHTS. THE AIRCRAFT CRASHED SECONDS LATER. IT IMPACTED THE GROUND IN A LEFT WING/NOSE SLIGHTLY LOW ATTITUDE AT HIGH SPEED. THERE WAS NO EVIDENCE OF PREIMPACT FAILURE/MALFUNCTION OF THE AIRFRAME, ENGINES, INSTRUMENTS, OR CONTROLS. THE PILOT HAD BEEN AWAKE FOR 22 HOURS WITH LITTLE OR NO REST. HE WAS NOT CURRENT FOR NIGHT FLIGHT. HIS IFR CURRENCY COULD NOT BE DETERMINED. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1990_DEN90FA184.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (spatial disorientation, pilot fatigue). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Embry-Riddle Scholarly Commons 2025 · Journal article (IJAAA)
Design, Implementation, and Testing of Spatial Disorientation Scenarios in a Modified Hexapod Motion Simulator
Abstract Investigations into aviation accidents aim to identify root causes and enhance safety. Despite advancements in safety measures, technology, and education, general aviation accident rates rema…
- SKYbrary (Eurocontrol) 2023 · SKYbrary article
Pilot Fatigue — SKYbrary Knowledge Base
SKYbrary pilot fatigue review — circadian biology, biomathematical models (SAFE/FAID), commuting impacts, regulatory frameworks (FAR 117 + EU 83/2014).
- NASA NTRS 2023 · Presentation
Nasa Pilot Fatigue Research: Past, Present & Future
Pilot fatigue research at NASA Ames has a long history, initiated by a Congressional request to investigate the magnitude of fatigue, sleep loss and circadian disruption in flight operations, and how …
- AOPA Air Safety Institute 2022 · Safety advisor
Safety Advisor: Spatial Disorientation
Safety advisor on the perceptual illusions that cause spatial disorientation: the leans, graveyard spiral, somatogravic and somatogyral illusions, false horizon, and Coriolis.
- FAA CAMI 2022 · CAMI technical report
Pilot Fatigue and Sleep Patterns in Long-Range and Ultra-Long-Range Operations
Field study of crew sleep and alertness during ultra-long-range commercial operations. Combines actigraphy, sleep diaries, and PVT-B reaction tests.
- NASA NTRS 2019 · Conference Paper
Evaluation of Low Cost, User-Centered Alerting Devices for the Mitigation of Flight Crew Spatial Disorientation
The National Aeronautics and Space Administration (NASA) is conducting research into technologies which have the potential to reduce flight crew Spatial Disorientation (SD).
Browse the full corpus — academia portal ↗