Avalon, CA, USA
N66819
BEECH A36
A witness observed the airplane lift off at midfield, then climb straight ahead and enter the clouds. The witness said that the winds were strong and gusty; it was clear to the north and east. A special aviation routine weather report (METAR) for the departure airport was issued at 1630. It stated that the winds were from 210 degrees at 16 knots gusting to 26 knots; visibility was 6 miles with mist. The skies were 200 feet broken, and 700 feet overcast. The temperature and dew point were both 11 degrees Celsius. The departure airport has a field elevation of 1,602 feet mean sea level; the VORTAC navigational unit is 171 degrees at 1.8 nm from the airport. The elevation of the VORTAC is 2,090 feet. The published instrument flight rules departure procedure from the airport for both runways 4 and 22 was to climb straight ahead to 2,300 feet, and then proceed on course. The pilot filed for direct to the VORTAC, direct to another location and then to the destination airport at 3,000 feet. Recorded radar data indicated the airplane made a 90-degree climbing left turn at 1,800 feet at the departure end of runway 22. Over the next couple of minutes, it turned left, then back toward the original course. It then made a 180-degree right turn, and reached a peak altitude of 2,400 feet. At some points during the maneuvering it was less than 400 feet above ground level. The airplane then began a descending left turn that reached descent rates of 4,000 feet per minute. The last target for the airplane was at an altitude of 1,800 feet and about 1/4 nautical mile (nm) from the accident site. The site was 175 degrees at 1.6 nm from the center of the airport, and was about 1/4 nm northwest of the VORTAC. The wreckage was in hilly terrain, and the airplane appeared to impact the ground in a level upright attitude. The debris path began near the mouth, and on the right side slope, of a canyon; it continued up the canyon toward rapidly rising terrain. The pilot had fewer than 400 hours total time, and fewer than 15 hours actual instrument time. Postaccident examination of the airframe and engine revealed no anomalies that would have precluded normal operation.
HISTORY OF FLIGHT On February 5, 2009, about 1642 Pacific standard time, a Beech A36, N66819, collided with terrain following a loss of control near Avalon, California. Skyblue USA LLC was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot and his two passengers were killed. The airplane sustained substantial damage to the wings, fuselage, and empennage from impact forces and a post crash fire. The charter flight departed Avalon’s Airport in the Sky about 1639, with an intended destination of John Wayne/Orange County Airport (SNA), Santa Ana, California. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed, but not activated. The airplane’s home base was SNA. The Federal Aviation Administration (FAA) supplied a plot of radar data that indicated the airplane departed SNA about 1202, and arrived at Catalina about 1225. The airport manager was on duty in the airport’s tower. He observed the airplane land, and the pilot and passengers deplane. The pilot was wearing a white shirt with epaulets, came up to the tower, and paid the landing fee. The pilot did not use the tower facilities to check weather. The pilot and his passengers boarded a taxi, and left the airport area. The airport manager observed the pilot and passengers return to the airport about 1630. After the pilot performed a preflight inspection, he and his passengers boarded the airplane. The pilot started the engine, and performed a run up in front of the tower. He taxied for takeoff, and made an immediate departure from runway 22. The airport manager saw the airplane lift off at midfield, climb straight ahead, and shortly thereafter, enter the clouds. He did not see the airplane again. The winds were strong and gusty; it was clear to the north and east. During the start, run up, and taxi, the engine sounded normal to him; it did not hesitate or backfire. He did not observe smoke, or any objects or fluids falling from it. He thought that the airplane had been to Catalina before, but did not recognize the pilot. The Federal Aviation Administration (FAA) issued a family concerned alert notification (ALNOT) for the overdue airplane. Search crews located the wreckage at 1007 PST on February 6. A review of recorded radar data noted a secondary 1200 visual flight rules (VFR) beacon code at a mode C reported altitude of 1,600 feet msl near the departure end of runway 22 at 1639:19. Thirty-two seconds later, the target was past the departure end of runway 22 and reporting 1,800 feet. The target made a 90-degree climbing left turn to the southeast. At 1640:42, it turned left, and then back to the southeast 18 seconds later at an altitude of 2,300 feet. At 1641:14, it began a 180-degree right turn, and reached a peak altitude of 2,400 feet 29 seconds later while tracking to the northwest. Comparing the flight track to a topographical map indicated that, at some points during the maneuvering, the airplane was less than 400 feet above ground level (agl). The target began a descending left turn, and lost 600 feet in 9 seconds, which computed to 4,000 feet per minute. The last target was at 1641:56, at a mode C altitude of 1,800 feet. The coordinates for the last radar return were 33 degrees 23.0 minutes north latitude 118 degrees 25.25 minutes west longitude. PERSONNEL INFORMATION A review of FAA airman records revealed that the 48-year-old pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. He had a second-class medical certificate issued on August 14, 2008. It had the limitations that the pilot must wear corrective lenses. Family members provided the Safety Board investigator with pilot logbook excerpts from November 23, 2007, to October 4, 2008. An examination of these excerpts indicated an estimated total flight time of 376 hours. Actual instrument time was 14.1 hours, and simulated instrument time was 50.2 hours. The pilot completed the Beechcraft Pilot Proficiency Program in October 2006. Examination of the pilot’s certified airman’s file indicated that he did not pass his first practical attempt for an instrument rating on August 20, 2006. The areas of disapproval were for GPS missed approach, and holding procedures. He successfully passed a retest on August 28, 2006. On the application for the rating, he indicated a total pilot-in-command time of 203 hours and 44 instrument hours. AIRCRAFT INFORMATION The airplane was a Beech A36, serial number E-2084. A review of airframe logbook excerpts revealed that the airplane had a total airframe time of 3,900 hours at the last annual inspection. The logbooks contained an entry for an annual inspection dated January 25, 2008. The engine was a Teledyne Continental Motors (TCM) IO-520-BB (51), serial number 285963. METEOROLOGICAL INFORMATION The pilot contacted an automated flight service station (AFSS) for a weather brief. He filed an instrument flight rules (IFR) flight plan at 1535. He filed for direct to the AVX very high frequency omni-directional radio range, tactical air navigation (VORTAC) navigational unit, direct Seal Beach, and then John Wayne Airport at 3,000 feet. The elevation of the AVX VORTAC is 2,090 feet, and it is 171 degrees at 1.8 nm from the airport. He stated that he had 3.5 hours of fuel and three people on board. He estimated 30 minutes en route, and anticipated a departure time of 1645. The closest official weather observation station was Avalon (KAVX). An aviation routine weather report (METAR) for KAVX was issued at 1451. It stated: winds from 170 degrees at 14 knots gusting to 22 knots; visibility 1/4 mile, mist, light rain, and fog; indefinite ceiling 100 feet overcast; temperature 11/52 degrees Celsius/Fahrenheit; dew point 11/52 degrees Celsius/Fahrenheit; and altimeter 29.99 inches of mercury. A special aviation routine weather report (METAR) was issued at 1630. It stated: winds from 210 degrees at 16 knots gusting to 26 knots; visibility 6 miles, mist; skies 200 feet broken, 700 feet overcast; temperature 11/52 degrees Celsius/Fahrenheit; dew point 11/52 degrees Celsius/Fahrenheit; and altimeter 29.98 inches of mercury. The National Weather Service (NWS) Surface Analysis Chart for 0000Z (1600 PST) depicted a low pressure system located on the California and Nevada border. There was an occluded front extending south that turned into a cold front extending south and southwest across south-central California. It continued into Baja California and into the Pacific Ocean east of the accident site. A mesoscale high pressure system was located behind the front immediately southeast of the Catalina Islands and along the California coast. Further west, another low pressure system was off shore with a trough of low pressure extending north-northeast to southwest. The station models in the vicinity of the accident site indicated general southwesterly winds at 10 to 25 knots, overcast skies, with light to moderate continuous rain. The NWS Weather Depiction Chart for 0100Z (1700 PST) depicted an area of IFR conditions over the Catalina Islands to coastal regions into Los Angles and Long Beach. Surrounding the area was an area of marginal VFR (MVFR) conditions. The station model for Catalina Island indicated that fog obscured the sky. AIRPORT INFORMATION The Airport/ Facility Directory, Southwest U. S., indicated that runway 22 was 3,000 feet long and 60 feet wide. The runway surface was asphalt. Avalon Airport has a field elevation of 1,602 feet mean sea level (msl). The published IFR departure procedure from Avalon for both runways 4 and 22 was to climb straight ahead to 2,300 feet, and then proceed on course. WRECKAGE AND IMPACT INFORMATION The accident site was about 175 degrees at 1.6 nm from the center of the airport, and was about 1/4 nm northwest of the AVX VORTAC. Investigators examined the wreckage at the accident scene. The coordinates for the accident site were 33 degrees 22.73 minutes north latitude 118 degrees 25.27 minutes west longitude. The global positioning satellite (GPS) elevation was 1,664 feet. The wreckage was in hilly terrain. The debris path began near the mouth, and on the right side slope of a canyon; it continued up the canyon toward rapidly rising terrain. The first identified point of contact (FIPC) was an impact crater, which had symmetrical ground scars on its left and right sides. Green lens fragments were a few feet past the outer edge of the right ground scar. One propeller blade and pieces of the nose landing gear assembly were in the FIPC. The debris path was along a magnetic heading of 058 degrees, and the main wreckage was 120 feet from the FIPC. The airplane came to rest inverted with the engine underneath it. Fire consumed most of the cabin area and center wing sections. MEDICAL AND PATHOLOGICAL INFORMATION The Los Angeles County Coroner completed an autopsy, and ruled the cause of death as multiple blunt force injuries. The FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot. Analysis of the specimens contained no findings for carbon monoxide, cyanide, and volatiles. The report contained the following findings for tested drugs: diphenhydramine detected in the liver. TESTS AND RESEARCH Investigators from the Safety Board, the FAA, Teledyne Continental Motors (TCM), and Hawker Beechcraft examined the wreckage at Aircraft Recovery Service, Littlerock, California, on March 25, 2009. Examination notes are in the public docket. The airframe manufacturer investigator determined that the flaps were in the retracted position, all landing gears were extended, and the fuel selector valve was in the right tank position. The investigators from the airframe and engine manufacturers noted no anomalies that would have precluded normal operation. ADDITIONAL INFORMATION Skyblue USA The pilot owned the company Skyblue USA. A link on the company’s web site was for tour packages of Southern California; one tour was for Catalina Island. The description of the tour noted that it began and ended from the airport on Catalina Island. Other tours started and ended in the San Diego area. All advertised tours indicated that they were within a 25-mile radius of the departure airport. The male passenger had contacted staff at the hotel where he was staying in regards to an airplane flight to Catalina for himself and his female companion. The front desk clerk was aware of Skyblue USA, because the pilot/owner had visited the hotel to inform them of his air tour business, and left contact information with the hotel. The front desk arranged for a rental car to take the two guests to Orange County Airport to meet the pilot, but they did not participate or observe any payment with regards to the flight. Entries in the pilot’s logbook indicated several demonstration tour flights for magazine reporters and concierges from area hotels. Other entries indicated tours, but did not specify that they were demonstrations. Catalina Island is 224 degrees at 31.84 nm from the Orange County airport. The Safety Board IIC interviewed the two company pilots. One pilot stated that he worked for the company from September 2006 until May 29, 2008, and made a total of 35 flights. He was not aware of a company flight standard operating procedures (SOP) manual. He indicated that pilots conducted safety briefs prior to every flight. There were no maintenance issues pending that he was aware of when he left the company. He flew numerous times with the accident pilot, including as a safety pilot on instrument flights. The pilot displayed intermediate level flight skills, and was good on instruments. The second pilot completed indoctrination and a flight check in a similar airplane at a different company. He made one tour flight for Skyblue USA on December 29, 2008. The owner indicated that he was not going to continue the business after the first of the year due to cost concerns.
The pilot’s failure to follow the published instrument departure procedures during the climb to cruise, and loss of control in instrument meteorological conditions. Contributing to the accident was the pilot’s lack of total experience in instrument meteorological conditions.
Source: NTSB Aviation Accident Database
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