Winslow, AR, USA
N1085D
BEECH A36
Before being vectored for an instrument approach to the destination airport, the airplane was in visual meteorological conditions above a layer of clouds where earlier reports indicated icing conditions. During the descent, and as the airplane approached the initial fix for the approach, the airplane entered instrument meteorological conditions. Air traffic control communications and radar data indicated that the airplane flew past the initial fix and through the approach course after the air traffic controller instructed the pilot to intercept the approach course. The airplane turned right toward, and again through the approach course, followed by an additional and larger heading correction to the left and through the approach course. The airplane then flew an increasingly erratic flightpath until it disappeared from radar. The applicable Pilot's Operating Handbook and Federal Aviation Administration-approved Airplane Flight Manual indicated that flight in icing conditions was prohibited. The challenging visibility conditions and the airplane's flight track were conducive to the onset of pilot spatial disorientation.
HISTORY OF FLIGHT On February 6, 2010, at 1143 central standard time, a Beech Aircraft Corporation A-36 airplane, N1085D, sustained substantial damage when it impacted terrain near Winslow, Arkansas, while on an instrument flight rules (IFR) approach to Drake Field Airport (FYV), Fayetteville, Arkansas. The personal flight was being conducted under the provisions of 14 Code of Federal Regulations Part 91 with an IFR flight plan. The instrument-rated private pilot, a pilot-rated passenger, and two other passengers were fatally injured. The cross-country flight originated from Memorial Field Airport (HOT), Hot Springs, Arkansas, with a planned arrival at FYV. Instrument meteorological conditions prevailed at the accident site at the time of the accident. According to transcripts of radio communications between the pilot and Razorback Approach Control (RAC), the pilot contacted RAC at 1128:01 and was told to proceed direct to GERTE, the initial approach fix for the localizer-type directional aid/distance measuring equipment (LDA/DME) runway 34 instrument approach procedure. GERTE is located 5.1 miles outside (south of) the final approach fix (AWEMO) and on the localizer course for the LDA/DME runway 34 instrument approach procedure. Radar data indicated that, about the time the pilot contacted RAC, the airplane was flying on an approximate heading of 310 toward GERTE at 6,000 feet mean sea level (msl). At 1128:28, RAC east radar controller (ER) 1 provided a changeover briefing to RAC ER2. During the briefing, ER1 stated the cloud tops were at 5,000 feet and "everybody's getting light rime in the clouds." At 1137:30, ER2 instructed the pilot to descend and maintain 4,000 feet msl. The pilot acknowledged the instruction, and radar data indicated that the airplane began a descent within 20 seconds of that instruction. At 1139:13, ER2 told the pilot he was "6 miles from the final approach fix" and to "turn right heading 3-1-0, maintain 4,000 [until] established on the localizer, cleared LDA/DME 34 Fayetteville." The pilot stated the radio transmission was not clear and asked the controller to repeat the transmission. The controller repeated the transmission and the pilot acknowledged the instruction. The airplane was descending and approaching 5,000 feet msl at the time of that radio exchange. At 1140:28, the pilot was told to contact FYV tower on frequency 128.0. At that time, the airplane was descending through 4,300 feet msl, nearly collocated with GERTE, and maintained an approximate 310 degree heading. At 1140:47, the pilot contacted the FYV tower controller and advised he was at 4,100 feet msl. The tower controller told the pilot, "runway 34, cleared to land, wind 350 at 8, altimeter 3013." The pilot acknowledged. There were no further communications with the pilot. After passing over GERTE and through the 349 degree localizer course, the airplane proceeded to about 0.7 mile left of the localizer course while making a right turn to about a 040 degree heading, back toward the localizer course. At 1141:35, the airplane passed through the localizer course and maintained a 040 degree heading until it was about 0.5 mile right of the localizer course. The airplane then began a left turn and crossed perpendicular to the localizer course at 1142:12, about 2 miles outside the final approach fix. For the remainder of the flight, the airplane's altitude varied between about 3,000 and 4,000 feet msl. The airplane also made several heading changes that differed by more than 180 degrees before the last radar return was recorded at 1143:21 at an altitude of 2,999 feet msl. The airplane impacted terrain 0.06 mile southeast of the last radar return, and about 3 miles outside the final approach fix at an approximate elevation of 2,000 feet. Three witnesses near the accident site reported hearing the engine running before impact, and two of these witnesses observed the airplane shortly before impact in a nose-low attitude. Two of the witnesses also reported hearing the airplane "circle" and pass over their home twice before it impacted. PERSONNEL INFORMATION The pilot, age 46, held a private pilot certificate with airplane single-engine land and instrument airplane ratings. He was issued a third-class medical certificate on July 20, 2009, with no restrictions. According to the pilot's logbook, at the time of the accident he had accumulated approximately 363 total hours, 27 hours of actual instrument flight, and 39 hours of simulated instrument flight time. In the 30 days before the accident, he had accumulated 11.5 total hours and 2.4 hours of actual instrument time. His last flight review occurred on August 3, 2009. The pilot-rated passenger, age 57, held a private pilot certificate for airplane single-engine land. There were no pilot logbooks located for the pilot-rated passenger during the investigation and he did not provide any flight hour information on his only application for a medical certificate dated March 3, 1981. AIRCRAFT INFORMATION The six-seat, low-wing, retractable gear airplane, serial number E-2985, was manufactured in 1995. The airplane was powered by a Teledyne Continental Motors IO-550-B engine, S/N 682110, rated at 300 HP, and equipped with a three-bladed McCauley variable pitch propeller. The most recent annual inspection was completed on September 1, 2009, and the airframe had accumulated 1,661 hours at the time of the inspection. The engine logbook was not located during the investigation. METEOROLOGICAL INFORMATION At 1110, the FYV ceiling and visibility were reported as overcast at 1,500 feet above ground level (agl) and 7 miles visibility. At 1153, the FYV ceiling and visibility were reported as broken clouds at 1,500 feet agl, overcast at 2,000 feet agl, and 9 miles visibility. The National Weather Service (NWS) Surface Analysis Chart for 1200 depicted overcast ceiling with no precipitation present over the majority of the accident region and no significant fronts. A NWS weather depiction chart from 1000 showed the majority of Arkansas under marginal visual flight rule conditions, with an area of IFR conditions near the accident site. Pilot reports made between 0900 and 1500 below 15,000 feet indicated that light to moderate clear air and rime icing was being encountered in the region. Cloud bases were reported as low as 1,800 feet agl, with cloud tops as high as 6,000 feet. According to radio transmission transcripts, automated terminal information service (ATIS) information LIMA was current at FYV at the time of the accident. No recordings or transcripts of ATIS information LIMA were located during the investigation. Investigators could not determine whether the pilot had obtained a weather briefing before the flight. WRECKAGE AND IMPACT INFORMATION The airplane impacted an open, grassy area near a residence. The area was surrounded by trees and farm buildings, and the ground was partially covered by shallow snow. The wreckage was aligned on an approximate 100 degree magnetic heading. All flight control surfaces and major airplane components were accounted for at the accident site. All landing gear was found in the retracted position. The engine and propeller blades were not visible upon initial inspection due to being covered by debris and dirt. During the extrication process, one blade was located in a vertical position. The blade did not exhibit any bending, leading-edge chips or gouges, or chordwise scratches and was loose in the propeller hub. The other two blades were located underneath the engine after the engine was lifted from the impact crater. Approximately 6 inches of the outer end of each blade were broken off and both blades exhibited leading edge gouges. One of the blades exhibited forward twisting. The right wing exhibited accordion deformation along the entire leading edge. The fuel cap was separated from the wing and located approximately 100 feet forward of the main wreckage. The fuel bladder was ruptured and had separated from the wing. The flap was attached to the wing and was in the retracted position. The aileron was present and attached to the wing. The empennage was attached to the main wreckage and was compressed between the rear of the cabin and the leading edge of the vertical stabilizer. The horizontal stabilizer, both elevators, elevator trim tab, and the rudder were attached to the empennage. The left wing exhibited accordion deformation along the entire leading edge. The fuel cap was separated from the wing and located approximately 100 feet forward of the main wreckage. The fuel bladder was ruptured and had separated from the wing. The flap was attached to the wing and was in the retracted position. The aileron was present and attached to the wing. The cabin area of the fuselage exhibited compression from the instrument panel to the rear of the cabin. The instrument panel was 612 inches below the surface of the ground, within the impact crater. The airspeed indicator was located and exhibited a needle slap mark on the instrument face at 149 knots. The standby compass was damaged, with the compass drum dislodged. The heading indicator was located at approximately the 140-degree mark on the compass drum. The altimeter indicated 2,140 feet and 30.05 was set in the Kollsman window. The remaining flight instruments were impact damaged and unreadable. Flight control continuity was confirmed from the elevator and rudder to aft of the rear forward-facing seats. Aileron flight control cables were traced from the aileron bell cranks to the center carry-through structure. No anomalies were noted with the flight controls. A postaccident examination revealed no airplane systems or engine anomalies that would have precluded normal operation prior to impact. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot on February 10, 2010, by the Medical Examiner Division of the Arkansas State Crime Laboratory, Little Rock, Arkansas. The autopsy findings concluded the cause of death was multiple traumatic injuries. Forensic toxicology was performed on specimens from the pilot by the Federal Aviation Administration (FAA) Civil Aerospace Medical Institute, Oklahoma City, Oklahoma. The toxicology report indicated that no testing for carbon monoxide or cyanide was performed and no ethanol or drugs were detected. No autopsy or toxicological testing were performed on the pilot-rated passenger. ADDITIONAL INFORMATION A Garmin GPSMAP 696 unit, an Electronics International UBG-16 Engine Monitor, a Garmin terrain awareness and warning system data card, and a Jeppesen navigation data card were removed from the wreckage and sent to the NTSB recorders laboratory for download. No data were recovered from any of the components. The applicable Beech Bonanza A36 Pilot's Operating Handbook and FAA-approved Airplane Flight Manual contained the following warning: "Flight in icing conditions prohibited." FAA Advisory Circular 60-4A, "Pilot's Spatial Disorientation," states the following concerning spatial disorientation while piloting an aircraft: "The attitude of an aircraft is generally determined by reference to the natural horizon or other visual references with the surface. If neither horizon nor surface references exist, the attitude of an aircraft must be determined by artificial means from the flight instruments. Sight, supported by other senses, allows the pilot to maintain orientation. However, during periods of low visibility, the supporting senses sometimes conflict with what is seen. When this happens, a pilot is particularly vulnerable to disorientation. The degree of disorientation may vary considerably with individual pilots. Spatial disorientation to a pilot means simply the inability to tell which way is 'up'."
The instrument-rated pilot's spatial disorientation and subsequent loss of airplane control during flight in instrument meteorological and conditions favorable for structural icing.
Source: NTSB Aviation Accident Database
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