# NTSB ATL03FA055: Beech A-36, N333RB, Milledgeville, GA, March 8, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 7, 2003, 22:52 local (Mar 8, 2003, 03:52 UTC) - Place: Milledgeville, GA - Coordinates: 33.154167, -83.240554 - Nearby events: https://openairdocs.org/map.md?lat=33.1542&lon=-83.2406&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report July 7, 2005 - Report: Approved by Office Director - Parties: FAA, Raytheon Aircraft Company - NTSB case key (mKey): 56629 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL03FA055 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56629/pdf - Page: https://openairdocs.org/ntsb/ATL03FA055 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with object, approach - faf/outer marker to threshold (ifr) - ifr procedure - improper, pilot in command (cause) - object - tree(s) - minimum descent altitude - not maintained, pilot in command (cause) - clearance - not maintained, pilot in command (cause) - weather condition - low ceiling (contributing factor) ## 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](https://openairdocs.org/deregistered/N333RB-2003-07-24), registration cancelled 2003-07-24, S/N E-1465, built 1979 (OpenAirDocs) - Reported make and model: Beech A-36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E1465 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: fatal; 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 (OpenAirDocs). - [Accident 20030307010419A](https://openairdocs.org/incident/20030307010419A), Mar 7, 2003: Beech A36, Milledgeville, GA, Destroyed, 1 fatal. (-23) On March 07, 2003, about 2245 eastern daylight time, a Beech A-36, N333RB, registered to rem leasing corp, and operated by the private pilot under the… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.