# NTSB ATL89FA196: Beech A-36, N25805, Chapel Hill, NC, August 12, 1989

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: August 11, 1989, 21:18 local (Aug 12, 1989, 01:18 UTC)
- Place: Chapel Hill, NC
- Location: 35.9283° N, 79.0401° W: Placed by OpenAirDocs: center of Chapel Hill, NC, within about 6 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=35.9283&lon=-79.0401&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 1 fatal
- Status: Completed, report September 11, 1992
- Report: Approved by Office Director
- NTSB case key (mKey): 7913
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL89FA196
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/7913/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=7913
- Page: https://openairdocs.org/ntsb/ATL89FA196

## 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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- In flight collision with object, approach
  - autopilot/flight director - undetermined (contributing factor)
  - emergency procedure - not followed, pilot in command (contributing factor)
  - autopilot - improper use of, pilot in command (contributing factor)
  - elevator trim - not corrected, pilot in command (contributing factor)
  - aircraft control - not maintained, pilot in command (cause)
  - fatigue, pilot in command (contributing factor)

## 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](https://openairdocs.org/deregistered/N25805-2014-10-27), registration cancelled 2014-10-27, S/N E-2310, built 1986 (OpenAirDocs)
- Reported make and model: BEECH A-36
- Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs)
- Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs)
- Category: Airplane
- Serial number: E2310
- Airframe hours: 314
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 71; 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

## 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 19890811028779A](https://openairdocs.org/incident/19890811028779A), Aug 11, 1989: Beech A36, Chapel Hill, NC, Destroyed, 1 fatal. Struck tree near airport. Unable turn off auto pilot. Trim full down at impact.

## Docket (1 files)

The files NTSB released with the investigation on February 16, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=7913. 20.9 MB in all.

- Full Accident Docket from Microfiche 41467A (item 1, .PDF, 20.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449334&FileExtension=.PDF&FileName=Full%20Accident%20Docket%20from%20Microfiche%2041467A-Master.PDF

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.