ATL89FA196

NTSB accident investigation · Beech A-36 · Chapel Hill, NC · August 12, 1989

Accident · FatalField investigationFinal report
Date
August 11, 1989, 21:18 local (Aug 12, 1989, 01:18 UTC)
Place
Chapel Hill, NC
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N25805Beech A-36
Weather
Visual (VMC) · Night/dark
Status
Completed · report September 11, 1992
Report
Approved by Office Director
FAA report
19890811028779A
Case key
7913

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

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Probable cause

The pilot's failure to maintain control of the airplane while maneuvering for a landing. Contributing factors were: the pilot's failure to follow the emergency procedures for an autopilot malfunction, and pilot fatigue.

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
Autopilot/flight director - undeterminedFactor
Emergency procedure - not followedPilot in commandFactor
Autopilot - improper use ofPilot in commandFactor
Elevator trim - not correctedPilot in commandFactor
Aircraft control - not maintainedPilot in commandCause
FatiguePilot in commandFactor

Analysis

At 2028, after a missed apch at destination, the plt reported he couldn't get the autopilot off & was fighting hard to control the airplane. ATC offered suggestions to disengage autopilot, including turning off master switch; plt reported no change. During the next 45 minutes the pilot was provided vectors and assistance; plt frequently did not respond to instructions. Final vectors were to Chapel Hill airport; radar data lost. Wreckage oriented over an area of a normal base to rwy 8. Elevator trim was found in a full tab-up (nose-down) position. Aprx 45 lbs of stick force would be necessary to hold the airplane level. The approved flight manual supplement for the king kfc 200 autopilot system contained emergency procedures for autopilot/electric trim malfunctions. These procedures require that the aircraft be retrimmed manually.

Aircraft

Registration
N25805
Reported as
Beech A-36
Category
Airplane
Serial number
E2310
Airframe hours
314
Engine
Continental IO-520-BB, 285 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
John Aire Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · January 18, 1989 · 10 hours before
Departed
ISO · Kinston, NC
Destination
W27 · Smithfield, NC
Flight plan
IFR

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
71
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
1,200 total

Weather

Conditions
Visual (VMC) · Night/dark
Wind
20° at 7 knots
Visibility
3 statute miles
Lowest ceiling
900 ft overcast
Temperature
66 °F, dew point 63 °F
Altimeter
30.00 inHg
Observed at
RDU, 20 nm away

Docket · 1

The files NTSB released with the investigation on February 16, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 20.9 MB in all.

FAA reports on this event · 1

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