TOPSFIELD, MA, USA
N6AP
BEECH A36
THE PILOT WAS RETURNING TO HIS TEMPORARY RESIDENCE AFTER THE 1ST DAY OF A PILOT PROFICIENCY COURSE. HIS ROUTE TOOK HIM OVER THE LWM VOR, WHERE HE WAS TO TRACK LEFT (ON 145 DEG COURSE) & INTERCEPT THE LOCALIZER (LOC) 157 DEGREE COURSE TO THE AIRPORT, VIA THE FINAL APPROACH FIX (FAF). THE FAF WAS ABOUT HALF WAY BETWEEN THE LWM VOR & THE AIRPORT. THE LOC & VOR EACH HAD DME. AFTER INTERCEPTING A 157 DEG COURSE TO THE VOR, THE PLANE CROSSED THE VOR & CONTINUED ON THE VOR 157 DEG RADIAL, PARALLELING THE LOC COURSE. AFTER PASSING THE VOR, THE PILOT REPORTED HIS DME FROM THE LWM VOR, RATHER THAN FROM THE LOC DME AT THE AIRPORT. HE REMAINED ABOVE THE 1800' MSL CROSSING ALTITUDE UNTIL ABOUT 2 MI PAST THE FAF. ABOUT 3 MI PAST THE FAF, THE AIRPLANE TURNED LEFT 27 DEGREES, FLEW ACROSS THE LOC COURSE, THEN BEGAN A DESCENDING RIGHT TURN. RADAR CONTACT WAS LOST AS THE PLANE DESCENDED BELOW 900'. IT STRUCK THE GROUND IN A DESCENDING RIGHT TURN. THE 2112 EDT WEATHER AT THE AIRPORT WAS IN PART: 100' OBSCURED, VIBILITY 1/4 MI WITH FOG.
HISTORY OF FLIGHT On October 8, 1993, about 2100 eastern daylight time, a Beech A-36, N6AP, owned and piloted by Marvin Feldman, was destroyed when it impacted the ground during an instrument approach, 2 miles north of the Beverly Airport, Beverly Massachusetts. The pilot was fatally injured. Instrument meteorological conditions prevailed and an instrument rules flight (IFR) plan had been filed for the flight operating under 14 CFR 91. The pilot was staying at a friends house in Beverly, Massachusetts, where he was house sitting and caring for the owner's pet. The pilot had just attended the first day of a Bonanza Society of America, Pilot Proficiency Program, conducted in Concord, New Hampshire. The 3 day program was to include flight instruction and a Bi-Annual Flight Review (BFR). At the conclusion of the first days events, instructors from the program drove the pilot to the Concord Airport (CON), where he had parked his airplane that morning. The pilot telephoned the Bangor Automated Flight Service Station (AFSS) from the airport. He obtained a weather briefing for an IFR flight from CON to the Beverly Airport (BVY), Beverly, Massachusetts. During the briefing the AFSS briefer stated, "...you're probably not going to get into...Beverly...they're reporting indefinite ceiling one hundred sky obscured one-half mile fog...If you want I'll check a couple of other stations around that area." The briefer then informed the pilot that the weather was better to the west and that Worchester, Massachusetts, was reporting scattered clouds and a visibility of 7 miles. The pilot of N6AP stated he appreciated that and, "...I've got my car there [BVY]." After a further discussion about weather at other airports the pilot stated, "...I could come in on the ILS, take a look and if it isn't there I can just turn around and go right back up the ILS and...go to...Lawrence [Lawrence Municipal Airport]." At the end of the briefing the pilot filed an IFR flight plan from CON to BVY and listed Lawrence Municipal as his alternate airport. About 2040, N6AP departed CON and was issued a clearance to 3000 feet by Manchester Approach Control. N6AP was handed off to Boston Approach Control and was advised to expect the Localizer Runway 16 (LOC 16) approach to BVY. According to the NTSB Radar Data Study, the pilot intercepted an approximate 157 degree course to the Lawrence VOR [LWM VOR] about 6 miles northwest of the VOR and flew that course to the VOR. The airplane flew over the VOR and continued on an approximate 157 degree course outbound from the VOR. N6AP was cleared for the LOC 16 approach to BVY by the Boston Controller and was instructed to contact BVY Tower. N6AP transmitted on Boston Approach Control frequency at 2058:14, "Beverly Tower, november six alpha papa with you four point five miles...from Lawrence [VOR]..." The Boston Controller advised N6AP that he was still on Boston's frequency. The pilot then contacted BVY Tower at 2058:41, and reported on their frequency 5 miles from the LWM VOR. Radar data confirmed that N6AP was approximately 5 miles from LWM and at an altitude of 2300 feet. The BVY Tower Controller cleared N6AP to land and advised him that he had a message for him. The pilot stated, "Uh, sir, I think I'm a little busy now can it wait till after I-----." The BVY Controller responded to N6AP with the current altimeter setting and, "...cleared to land runway one six, advise either airport in sight or missed approach." N6AP replied, "Affirmative, I see some lights off at my eleven o'clock, not sure, those must be the town I guess." The BVY Controller asked N6AP if was based out of Beverly and at 2059:31, N6AP replied affirmative. About 2102, Boston Approach Control advised the BVY Tower Controller by telephone of a low altitude alert on N6AP. The BVY Controller transmitted a low altitude warning to N6AP at 2102:21. There was no further response from N6AP. During the flight from CON to BVY, N6AP had been assigned an altitude of 3,000 feet. When the pilot was cleared by Boston Approach Control to descend on the approach as published, the airplane was between the LWM VOR and the TAITS intersection, the LOC 16 final approach fix. The minimum altitude published for that segment of the approach was 1,800 feet. Radar data indicates that the airplane descended over the next 6 miles, reaching a minimum altitude of 2000 feet, 2 miles past TAITS. The minimum altitude published for crossing TAITS was 1,800 feet. Past TAITS, the next published altitude for the approach was the minimum descent altitude of 580 feet. During the descent to 2,000 feet the airplane continued to track on a course consistent with the 157 degree radial from the LWM VOR. At 0100:09, while at an altitude of 2,000 feet and at the extreme right edge of the localizer course, the airplane turned left about 27 degrees and flew across the localizer course. This was followed by a right descending turn. The last Boston Radar observation showed N6AP in a descending right turn, at an altitude of 900 feet above mean sea level, about 2 miles north of the Beverly Airport. The airplane had completed a 270 degree right turn in the vicinity of the localizer course. According to the owner of the residence where the airplane crashed: "I heard a noise that sounded like a large truck or motorcycles, and then it sounded like a rocket over the house. This sound was immediately followed by a loud crash which shook the house. I turned to the back windows and saw our woods in flames..." The accident occurred during the hours of darkness at approximately 42 degrees, 37 minutes north latitude, and 70 degrees, 57 minutes west longitude. PERSONNEL INFORMATION The pilot, Marvin E. Feldman, held a Private Pilot Certificate with a rating for airplane single engine land and instrument airplane. His most recent Federal Aviation Administration (FAA) Second Class Medical Certificate was issued in June 1993. Mr. Feldman's pilot log book was destroyed in the post crash fire. Mr. Feldman's total flight time was estimated to be about 750 hours with 30 hours in the A-36. METEOROLOGICAL INFORMATION The weather at the time of the accident at Beverly Airport was an indefinite ceiling, 100 foot sky obscured, visibility 1/4 mile with fog. The weather reported to the pilot of N6AP by the Bangor AFSS during the weather briefing was: Beverly- indefinite ceiling 100 hundred sky obscured, visibility 1/2 mile and fog. Lawrence- 300 overcast, 1 mile visibility with light drizzle and fog. Bedford- 500 overcast, visibility 1 mile and fog. Concord- 800 broken, 20,000 overcast, visibility 5 and fog. WRECKAGE AND IMPACT INFORMATION The airplane wreckage was examined at the accident site on October 9, 1993. The examination revealed that all major components of the airplane were accounted for at the scene, and that the airplane came to rest on an approximate magnetic heading of 80 degrees. An initial impact scar was discovered at the edge of a swimming pool at a private residence. Pieces of green lens and sheet metal from the right wing were found in the pool. A ground scar was observed in the dirt 12 feet long, leaving the pool on a magnetic heading of 255 degrees. A piled stone wall about 4 feet high and 2 feet wide, 20 feet from the pool edge, was knocked down. A 20 foot section of 4 foot high chain link fence with supporting steel posts, 24 feet from the pool, was torn out. A path of leveled trees and airplane pieces continued to an impact hole, 62 feet from the pool. This hole contained airplane debris and an engine valve spring. The nose of the airplane wreckage was 93 feet from the pool edge. The pilot had been ejected from the airplane and was found 20 feet beyond the wreckage. An odor of gasoline was present in the vicinity of the 12 foot ground scar. A path of burned debris was observed along the 100 foot path to the wreckage, which had been consumed by fire. The main wreckage was upright with the main gear retracted and the flaps in the approach setting. The nose wheel and strut were found about 30 feet beyond the main wreckage. Control continuity was established from the base of the yoke through the cables to the elevator, rudder, and the aileron attaching points. The engine was separated from the fuselage and found 16 feet beyond the nose of the airplane. The right front of the engine case was holed. All cylinders displayed evidence of external impact damage with the number six cylinder rocker arms missing and the valve stems protruding from the cylinder. Other components separated from the engine and found at the scene included both magnetos, the vacuum pump, the fuel pump, the fuel control unit, the starter and the alternator. The left magneto sparked when rotated by hand. The right magneto would not rotate due to impact damage. The fuel screen was removed and observed to be clean. The fuel pump was attached to the fuel control unit. The unit could be turned by a hand tool and appeared functional. A section of the propeller hub remained attached to the crankshaft. The three propeller blades were separated from the hub. One intact propeller blade was found in the vicinity of the chain link fence to the right of the wreckage path. Another intact propeller blade was found about 15 feet beyond the chain link fence on the right side of the wreckage path. The two pieces of the third blade were found on the left side of the wreckage path near the impact hole 62 feet from the pool. All blades showed evidence of impact damage with chord wise twisting of the blades, leading edge gouges, and chord wise scratching. Examination of the inside of the pilot's artificial horizon gyro revealed rotational scoring on the inside walls. MEDICAL AND PATHOLOGICAL INFORMATION At the request of the family, an autopsy was not performed on the Orthodox Jewish pilot. The results of an examination by Dr. Richard Evans, of the Massachusetts State Medical Examiners Office, revealed that the pilot died of, "multiple blunt traumatic injuries." The toxicological testing report, from the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, revealed negative for cyanide. Specimens were unsuitable for analysis for drugs and carbon monoxide. Ethanol and acetaldehyde found in the kidney fluid was attributed to putrefaction due to the post crash fire. ADDITIONAL INFORMATION The pilot purchased the airplane in May 1993. He listed 30 hours in this type of airplane on his application to attend the Bonanza Society of America course. The pilot's course deviation indicator display was set to a 157 degree course. The airplane was equipped with a single Distance Measuring Equipment (DME) display which was destroyed. The single display allowed the pilot to view only one DME signal at a time. The LWM VOR and the Beverly LOC each had a separate DME Channel. The pilot listed the Lawrence Municipal airport as his alternate airport on the flight plan that he filed with Boston AFSS. A forecast was not received by the pilot for LWM, but the current weather given to him by the AFSS was 300 overcast and a visibility of 1 mile. According to Federal Aviation Regulations, standard alternate minimums for a precision approach requires a weather forecast for a minimum of a 600 foot ceiling with 2 miles visibility. All of the LWM approaches are listed as A/NA. The definition in the National Oceanic Atmospheric Administration (NOAA) approach book states, "NA means alternate minimums are not authorized due to unmonitored facility or absence of weather reporting service." According to the Airman's Information Manual, a graveyard spiral is an observed loss of altitude during a coordinated constant rate turn that has ceased stimulating the motion sensing system, and can create the illusion of being in a descent with the wings level. The disoriented pilot will pull back on the controls, tightening the spiral and increasing the loss of altitude. The airplane wreckage was released on October 9, 1993, to Sergeant Dana Sanger, of the Topsfield Police Department.
FAILURE OF THE PILOT TO FOLLOW THE PUBLISHED IFR PROCEDURE, AND HIS FAILURE TO CORRECT A SPIRAL AFTER BECOMING SPATIALLY DISORIENTED.
Source: NTSB Aviation Accident Database
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