ATL03FA055

NTSB accident investigation · Beech A-36 · Milledgeville, GA · March 8, 2003

Accident · FatalField investigationFinal report
Date
March 7, 2003, 22:52 local (Mar 8, 2003, 03:52 UTC)
Place
Milledgeville, GA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N333RBBeech A-36
Weather
Instrument (IMC) · Night
Status
Completed · report July 7, 2005
Report
Approved by Office Director
Parties
FAA, Raytheon Aircraft Company
FAA report
20030307010419A
Case key
56629

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot's improper IFR procedure by which he failed to maintain the minimum descent altitude, and his failure to maintain obstacle clearance. A factor was low the ceiling.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with objectApproach - faf/outer marker to threshold (ifr)
Ifr procedure - improperPilot in commandCause
Object - tree(s)
Minimum descent altitude - not maintainedPilot in commandCause
Clearance - not maintainedPilot in commandCause
Weather condition - low ceilingFactor

Analysis

Upon arriving at the destination airport, the pilot was issued an approach clearance for the GPS runway 10 approach. Approximately 12 minutes later, the pilot reported a missed approach. The pilot was issued another approach clearance and subsequently reported another missed approach. At 2236:29, the pilot was issued a third approach clearance. At 2249:07 the airplane was 6.6 miles from the airport, at 1200 feet, when radar contact with the airplane was lost. At 2300, a local resident reported a burning airplane in a field 2,350 feet from the approach end of runway 10. Post-accident examination of the accident site revealed that wreckage debris was scattered over an area 450 feet long and 75 feet wide. There were several areas along the wreckage path where there was fire damage, including the main wreckage. Examination of the airplane revealed both wing assemblies were lodged 53 feet and 47 feet above the ground in two trees approximately 20 feet apart. The cockpit and cabin areas of the airframe exhibited extensive fire damage. The empennage was intact and free from fire damage. The three-blade propeller had chord-wise scarring and leading edge gouges on all blades. The airplane's engine rotated and compression was noted in all six cylinders. Examination of the airplane failed to disclose any mechanical failures or system malfunctions. At 2253, Middle Georgia Regional Airport, Macon, Georgia, weather reporting facility, 33 nautical miles southwest of the accident site, reported overcast clouds at 300 feet, and temperature and dew point of 11 degrees Celsius. According to the Instrument Approach Procedure for GPS Runway 10, Milledgeville/Baldwin County, the minimum descent altitude (MDA) was 900 feet above mean sea level, 516 feet above the airport elevation.

Factual narrative

History of flight

On March 7, 2003, at 2252 eastern standard time, N333RB, a Beech A-36, owned and operated by REM Leasing Corporation, collided with trees and the ground 2,350 feet from the approach end of runway 10 and burst into flames at Baldwin County Airport, Milledgeville, Georgia. The personal flight was operated under the provisions of Title 14 CFR Part 91 and instrument flight rules (IFR). Instrument meteorological conditions prevailed at the time of the accident and an IFR clearance had been issued. The airplane sustained substantial damage. The private pilot was fatally injured. The flight departed Dexter, Missouri, on March 7, 2003, at an undetermined time.

At 2159:00, the pilot established initial radio contact with Atlanta Approach Air Traffic Control, after being handed off from Atlanta Center. At 2159:25, the pilot was issued an IFR clearance to Baldwin County Airport via direct at 4,000 feet. At 2159:47, the pilot was instructed to proceed to Aznax initial approach fix, maintain 2,400 feet until established on the approach, and then cleared for the GPS runway 10 approach. At 2212:13, the pilot contacted Atlanta Approach and reported a missed approach. The pilot requested and was issued clearance for a second GPS runway 10 approach, with Aznax as the initial approach fix. At 2236:29, the pilot reported a second missed approach, then requested and was issued clearance for a third GPS runway 10 approach, with Aznax as the initial approach fix. At 2249:07, radar contact with the airplane was lost. At 2300, a local resident found the airplane burning in an open field.

Radar data information

A review of radar data revealed that during the first approach to land, radar contact with the airplane was lost 4.06 miles from the airport at 1700 feet. During the second approach to land, radar contact with the airplane was lost 5.06 miles from the airport at 1400 feet. During the third approach to land, radar contact with the airplane was lost 6.6 miles from the airport at 1200 feet.

Aircraft information

Aircraft or engine logbooks were not recovered for examination.

Meteorological information

At 2116, the pilot called the Macon Flight Service Station Flight Watch 01 and stated that he was twenty-one miles southwest of Chattanooga, Tennessee, enroute to Milledgeville, Georgia. He requested the weather in the Atlanta area and Macon, which they provided. He then issued a pilot report stating that he was in the clear with outside temperature of plus four degrees at nine thousand and a tailwind from three zero zero degrees at thirty nine knots.

At 2253, Middle Georgia Regional Airport, Macon, Georgia, weather reporting facility, 33 nautical miles southwest of the accident site, reported the winds from 070 degrees magnetic, at six knots, visibility of seven statute miles, overcast clouds at 300 feet, temperature and dew point of 11 degrees Celsius, and altimeter setting of 30.16 inches of mercury.

Personnel information

The pilot was issued a private pilot certificate on September 29, 1989, with ratings for airplane single-engine land and instrument airplane. He held a valid third class medical certificate issued August 24, 2001, with the restrictions "must have available glasses for near vision," and "miscellaneous restriction assigned." According to the pilot's medical certificate application, he reported his total flight time as 3,300 hours.

Wreckage and impact information

Post-accident examination of the accident site revealed that wreckage debris was scattered over an area 450 feet long and 75 feet wide, oriented along a heading of 100 degrees magnetic, along the extended centerline of the runway 10. Examination of the accident site disclosed that there were several areas along the wreckage path where there was fire damage including the main wreckage.

Examination of the airplane revealed both wing assemblies were lodged 53 feet and 47 feet above the ground in two trees approximately 20 feet apart. The cockpit and cabin areas of the airframe exhibited extensive fire damage. Flight control cables were observed intact from both aileron bell cranks to both wing roots and from the empennage to the rear cabin seats. The empennage was intact and free from fire damage. The rudder and elevator traveled freely from stop to stop. The fuel selector valve was set to the left fuel tank and the screen was free of debris. The landing gear and flaps were fully extended.

Further examination revealed the three-blade propeller had chord-wise scarring and leading edge gouges on all blades. The airplane's engine rotated and compression was noted in all six cylinders. Both magnetos sparked on all ignition towers when the drive assembly was rotated. The examination revealed that the ignition harness and leads were fire damaged. The engine-driven vacuum pump drive was intact and rotated freely, and scoring was noted inside the housing when the pump assembly was disassembled. The drive coupling was intact and rotated with minor binding. Crankshaft continuity was confirmed when the rear accessory section was rotated. The accessory section of the engine assembly sustained fire damage, therefore the engine fuel pump and other installed components were fire damaged. Examination of the airplane failed to disclose any mechanical failure or system malfunction.

Medical and toxicological information

The Medical Examiner's Office of the Georgia Bureau of Investigation, Macon, Georgia, performed the autopsy of the pilot on March 10, 2003. The cause of death was reported as "multiple blunt force trauma". The Forensic Toxicology Research Section, Federal Aviation Administration, Oklahoma City, Oklahoma, performed postmortem toxicology of specimens from the pilot. The results were negative for carbon monoxide, cyanide, ethanol, and drugs.

Additional information

According to the Instrument Approach Procedure for GPS Runway 10, Milledgeville/Baldwin County, the minimum descent altitude (MDA) was 900 feet above mean sea level, 516 feet above the airport elevation.

According to the Baldwin County Airport manager, on March 7, 2003, the airport and runway inspections were unremarkable.

The aircraft wreckage was released to the assigned insurance adjuster with USAIG insurance company.

Aircraft

Registration
N333RB
Reported as
Beech A-36
Category
Airplane
Serial number
E1465
Engine
Continental IO-520-BR0-15, 285 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Utility
Departed
DEX · Dexter, MO
Destination
MLJ · Milledgeville, GA
Flight plan
IFR
Airport
MLJ · Baldwin County, runway 10, 5,020 × 100 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
65
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
3,300 total

Weather

Conditions
Instrument (IMC) · Night
Wind
70° at 6 knots
Visibility
7 statute miles
Lowest ceiling
300 ft overcast
Temperature
52 °F, dew point 52 °F
Altimeter
30.15 inHg
Observed at
MCN, 33 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.