# NTSB BFO94FA103: Beech A-36, N1525G, Brainerd, MN, June 17, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 17, 1994, 10:55 local (15:55 UTC) - Place: Brainerd, MN - Coordinates: 46.349868, -94.190834 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=46.3499&lon=-94.1908&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal, 1 serious - Status: Completed, report October 31, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 8849 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=BFO94FA103 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8849/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=8849 - Page: https://openairdocs.org/ntsb/BFO94FA103 ## Probable cause THE PILOT'S FAILURE TO FOLLOW THE PUBLISHED MISSED APPROACH PROCEDURE, AND HIS FAILURE TO OBTAIN AND/OR MAINTAIN ADEQUATE ALTITUDE TO AVOID COLLISION WITH THE TERRAIN. FACTORS IN THE ACCIDENT WERE: THE PILOT'S LACK OF INSTRUMENT FLYING EXPERIENCE, AND THE CONTROLLER'S FAILURE TO FOLLOW STANDARD PROCEDURES AND TO PROVIDE MORE COMPLETE AND HELPFUL GUIDANCE TO THE INEXPERIENCED PILOT DURING THE APPROACH. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, missed approach (ifr) - weather condition - fog (contributing factor) - weather condition - rain (contributing factor) - missed approach - performed, pilot in command - ifr procedure - not followed, pilot in command (cause) - lack of total instrument time, pilot in command (contributing factor) - proper altitude - not obtained/maintained, pilot in command (cause) - artcc service - inadequate, atc personnel(artcc) (contributing factor) ## Analysis THE AIRPLANE WAS ON AN IFR FLIGHT PLAN. PRIOR TO THE APPROACH, THE PILOT TOLD ATC THAT HE 'NEEDED ALL THE HELP I CAN GET. I'M KIND OF NEW AT THIS.' HE WAS THEN CLEARED TO DESCEND AND BEGAN RECEIVING RADAR VECTORS FOR THE ILS APPROACH. THE AIRPLANE BEGAN TO HEAD TOWARDS A NEARBY VOR AFTER BEING VECTORED TO THE LOCALIZER COURSE. THE PILOT RADIOED THAT HE WAS NOT ON THE LOCALIZER AND REQUESTED ASSISTANCE. ATC PROVIDED ANOTHER VECTOR AND CLEARED THE AIRPLANE FOR THE APPROACH. THE AIRPLANE INTERCEPTED THE LOCALIZER AND THEN DISAPPEARED FROM RADAR. RADIO COMMUNICATION WAS LOST AFTER THE PILOT DECLARED A MISSED APPROACH. THE AIRPLANE IMPACTED TERRAIN SOUTH OF THE AIRPORT. THE PILOT HAD RECEIVED HIS INSTRUMENT RATING 6 MONTHS BEFORE THE ACCIDENT. SEVERAL PROCEDURES SPECIFIED IN THE ATC HANDBOOK WERE NOT FOLLOWED BY THE CONTROLLER. AFTER THE PILOT INITIALLY BEGAN TO STRAY FROM THE LOCALIZER COURSE, HE WAS NOT INFORMED OF HIS POSITION RELATIVE TO THE LOCALIZER, NOR WAS AN INQUIRY MADE AS TO THE PILOT'S INTENTIONS. IN ADDITION, THE VECTOR PROVIDED TO INTERCEPT THE LOCALIZER COURSE RESULTED IN AN INTERCEPT ANGLE OF 40 DEG; THE ATC HANDBOOK STIPULATES A MAXIMUM INTERCEPT ANGLE OF 30 DEG. ## Factual narrative HISTORY OF FLIGHT On June 17, 1994, about 1055 central daylight time, a Beech A-36, N1525G, operated by the owner/pilot, impacted terrain in Brainerd, Minnesota, during a missed approach to runway 23. The airplane was destroyed. The certificated private pilot and two passengers were fatally injured. The remaining passenger was seriously injured. Instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed. The personal flight departed from Lincoln, Nebraska, at 0825 and was en route to Brainerd. The flight was conducted under 14 CFR 91. According to FAA air traffic control (ATC) documentation, including transcripts of voice recordings and radar data (attached), the pilot received three preflight weather briefings by the Columbus Automated Flight Service Station (AFSS) on the morning of the accident prior to departure. The last briefing occurred at 0745. At 0819, the pilot was issued an IFR clearance from Lincoln to Brainerd. The pilot was cleared for takeoff at 0825. During the following two hours, the airplane flew at a cruising altitude of 9,000 feet mean sea level (msl) and was in communication with Lincoln ATC tower, Omaha Approach Control, Sioux City Approach Control, and finally, the Minneapolis Air Route Traffic Control Center (ARTCC). During this time period, the pilot twice requested and received approval to deviate from the intended course due to weather conditions. The pilot did not report any problems with the airplane. At 1018, the Minneapolis ARTCC controller advised the pilot to plan for an Instrument Landing System (ILS) approach for runway 23 at the Crow Wing County Regional Airport in Brainerd. The pilot responded with "...thank you, I'll appreciate all the help I can get. I'm kind of new at this." The controller responded with "roger." At 1024, the pilot was issued a pilot's discretion descent to 6,000 feet msl. During the following 15 minutes, the pilot was cleared to descend to 4,000 feet msl and received vectors for the ILS Runway 23 approach. At 1039:36, the controller advised the pilot to "... turn left heading two four zero to join the localizer." The pilot acknowledged. At 1040:49, the controller stated: "Two five golf I show you on the localizer nine miles northeast of the marker..." and cleared the flight for the approach. The pilot acknowledged. According to a Recorded Radar Study performed by the Safety Board (attached), the airplane's flight path had just grazed the "full-fly-right" boundary of the localizer course. This boundary defines the region at which the needle on the airplane's localizer navigation instrument will begin to provide navigational guidance if the corresponding localizer frequency is selected. Immediately after grazing the boundary, the airplane began to fly away from the localizer toward the Brainerd Very High Frequency Omni-directional Range (VOR) transmitter. At 1042:03, the pilot radioed "... I don't show myself on the course, where are you showing me?" The controller responded "... I show you a little left of course now, turn back right to a two seventy heading to join ..." The pilot acknowledged. The 270 degree vector issued by the controller was 40 degrees from the final approach course. The position of the airplane at the time of this communication was two nautical miles south of the full-fly-right boundary of the localizer. During the following three minutes, the airplane turned to the left and penetrated the full-fly-right boundary of the localizer. During this time, the airplane descended from 3,500 feet msl to 2,700 feet msl. At 10:44:55, radar contact was lost and never regained; the airplane was located about 3 miles from the final approach fix. At 1045:32, the controller asked the pilot, "... are you on the localizer now sir, or do you want to make a turn." The pilot did not respond. About five minutes later, at 1050:11, the pilot contacted the controller and stated that he "... missed the approach, on a heading of zero six zero degrees at two thousand." The controller then instructed the pilot to climb and maintain 4,000 feet, and he asked the pilot if he would like to "... try the ILS on your own navigation or would you like me to give you a vector for it?" The pilot did not respond and was not heard from again. The airplane was found about 1125 in a wooded area 2.79 nautical miles south of the airport. In an interview, the surviving passenger stated that the pilot, the pilot's father, and the pilot's son wanted to fly to Brainerd for a weekend of fishing. The surviving passenger was a friend of the pilot; he stated that he was on the flight because he wanted to "pick up a ride" to his summer home in Brainerd. The passenger was seated in an aft-facing seat on the left side of the cabin behind the pilot. The right front seat was occupied by the pilot's father, and the right rear seat, which was forward facing, was occupied by the pilot's son. The passenger stated that he was not wearing an intercom during the flight and could not hear conversations from the pilot; however, he could see and hear the pilot's son seated across from him. The passenger stated that the flight departed from Lincoln, Nebraska on the morning of the accident after the pilot received a weather briefing and had the airplane "topped off" with fuel. The airplane was flown at a cruising altitude of 9,000 feet. During the flight, some turbulence was encountered as the airplane passed through "a couple of fronts," but the weather was "not violent" during the approach into the Brainerd area. Visibility, however, was poor, according to the passenger. During the first approach to the airport, the passenger recalled flying parallel to a road after they had broken out of the clouds. He stated that the airport was nowhere in sight, so the pilot began to climb back up again. The passenger remembered maneuvering for a second approach to the airport that involved several "left turns." The pilot's son told the surviving passenger that they "were going down" and the passenger recalled telling him "its going to be alright." He said the airplane was "banked a little to the left" in a descent. The passenger then saw trees and something streaming out of the left wing just prior to impact. He characterized the time span from the missed approach to the impact as "short." After impacting terrain, the passenger walked to a farm house and telephoned local authorities. The passenger stated that at no time did he perceive any indications of mechanical malfunctions with the engine or the airplane. The accident occurred during the hours of daylight at 46 degrees, 22.60 minutes North and 94 degrees, 04.61 minutes West. PERSONNEL INFORMATION The pilot, age 45, was a certificated private pilot with a rating for single engine land airplanes. The pilot received an instrument rating on December 6, 1993. According to FAA records, the pilot was issued a FAA Second Class Medical Certificate on August 26, 1993, with no limitations. The pilot's logbook was not recovered. According to the pilot's FAA Airman Certificate and/or Rating application dated December 6, 1993, the pilot reported 140 hours of total flight time, including 61 hours in type and 47 hours of instrument instruction. AIRCRAFT INFORMATION The airplane, a 1988 Beech A-36, was co-owned by the pilot. He became a partner in the purchase of the airplane on June 8, 1994. The airplane was powered by a 300-horsepower Continental IO-550 engine and a controllable three-blade McCauley propeller. It had retractable landing gear and flaps. The airplane was also equipped with the following radio communications and navigational equipment: - King KFC-150 2-axis Flight Control System - King KY-196A Communication Transceiver - King KNS-81 Navigatio ## Aircraft - Registration: N1525G (not matched to a registry record) - Reported make and model: BEECH A-36 - Category: Airplane - Serial number: E-2462 - Airframe hours: 1260 - Engines: CONTINENTAL IO-550-B(6) 300 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Duncan Aviation Inc. & T.Hayes - Registered owner: Duncan Aviation Inc. & T.Hayes - Airworthiness certificate: Standard, Utility - Last inspection: 100 hour, January 7, 1994, 110 hours before - Departed: LNK, LINCOLN, NE - Flight plan: IFR - Airport: BRD, Crow Wing County Regional, runway 23, 6,500 × 150 ft ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 150 total, 80 as pilot in command, 4 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: calm - Visibility: 3 statute miles - Lowest ceiling: 500 ft broken - Temperature: 61 °F, dew point 59 °F - Altimeter: 30.00 inHg - Observed at: BRD, 3 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 19940617015399A](https://openairdocs.org/incident/19940617015399A), Jun 17, 1994: Beech A36, Brainerd, MN, Destroyed, 1 fatal. Crashed on missed approach in IMC. VFR pilot low time. ## Docket (21 files) The files NTSB released with the investigation on March 25, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=8849. 3.7 MB in all. - Supplement a (item 1, PDF, 2 pages, 177 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13445304&FileExtension=pdf&FileName=Supplement%20A-Master-Rel.pdf - Supplement b (item 2, PDF, 4 pages, 234 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13444472&FileExtension=pdf&FileName=Supplement%20B-Master-Rel.pdf - Supplement I (item 3, PDF, 3 pages, 183 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13445307&FileExtension=pdf&FileName=Supplement%20I-Master-Rel.pdf - Supplement k (item 4, PDF, 5 pages, 303 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13444610&FileExtension=pdf&FileName=Supplement%20K-Master-Rel.pdf - Supplement n (item 5, PDF, 2 pages, 134 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13445310&FileExtension=pdf&FileName=Supplement%20N-Master-Rel.pdf - Supplement s (item 6, PDF, 1 page, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13491810&FileExtension=pdf&FileName=Supplement%20S-Master-Rel.pdf - NTSB recorded radar study (item 7, PDF, 21 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13482980&FileExtension=pdf&FileName=NTSB%20Recorded%20Radar%20Study-Master-Rel.pdf - Record of interview (item 8, PDF, 2 pages, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13459009&FileExtension=pdf&FileName=Record%20of%20Interview-Master-Rel.pdf - Terminal procedures chart for ILS rwy 23 approach (item 9, PDF, 1 page, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13496357&FileExtension=pdf&FileName=Terminal%20Procedures%20Chart%20for%20ILS%20RWY%2023%20Approach-Master-Rel.pdf - Transcript of radio communications (item 10, PDF, 9 pages, 190 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13482993&FileExtension=pdf&FileName=Transcript%20of%20Radio%20Communications-Master-Rel.pdf - FAA report of aircraft accident (item 11, PDF, 5 pages, 265 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13459013&FileExtension=pdf&FileName=FAA%20Report%20of%20Aircraft%20Accident-Master-Rel.pdf - ATC personnel statements (item 12, PDF, 4 pages, 131 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13491813&FileExtension=pdf&FileName=ATC%20Personnel%20Statements-Master-Rel.pdf - ATC radar plot (item 13, PDF, 3 pages, 153 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13459018&FileExtension=pdf&FileName=ATC%20Radar%20Plot-Master-Rel.pdf - FAA waiver for ATC vectoring (item 14, PDF, 1 page, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13458904&FileExtension=pdf&FileName=FAA%20Waiver%20for%20ATC%20Vectoring-Master-Rel.pdf - Excerpt from ATC handbook (item 15, PDF, 1 page, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13491817&FileExtension=pdf&FileName=Excerpt%20from%20ATC%20Handbook-Master-Rel.pdf - Statement of party representatives to NTSB investigation (item 16, PDF, 1 page, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13488722&FileExtension=pdf&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master-Rel.pdf - Release of aircraft wreckage NTSB form 612015 (item 17, PDF, 2 pages, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13482997&FileExtension=pdf&FileName=Release%20of%20Aircraft%20Wreckage%20NTSB%20Form%20612015-Master-Rel.pdf - Toxicological report (item 18, PDF, 1 page, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13496472&FileExtension=pdf&FileName=Toxicological%20Report-Master-Rel.pdf - Photo 1 overall view of wreckage (item 19, PDF, 1 page, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13491821&FileExtension=pdf&FileName=Photo%201%20%20Overall%20view%20of%20wreckage-Master-Rel.pdf - Photo 2 engine and propeller note s-bending and chordwise scratching on blade tip (item 20, PDF, 1 page, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13482008&FileExtension=pdf&FileName=Photo%202%20%20Engine%20and%20propeller%20%20Note%20S-bending%20and%20chordwise%20scratching%20on%20blade%20tip-Master-Rel.pdf - Photo 4 sheared trees and ground scar found along the beginning of the wreckage distribution path note wreckage in b (item 21, PDF, 1 page, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13458907&FileExtension=pdf&FileName=Photo%204%20%20Sheared%20trees%20and%20ground%20scar%20found%20along%20the%20beginning%20of%20the%20wreckage%20distribution%20path%20%20Note%20wreckage-Master-Rel.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.