# NTSB CEN13FA006: Beech A36, N32GP, Mabank, TX, October 6, 2012 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 6, 2012, 09:45 local (14:45 UTC) - Place: Mabank, TX - Coordinates: 32.4775, -96.065002 - Nearby events: https://openairdocs.org/map.md?lat=32.4775&lon=-96.0650&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report January 30, 2014 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Honeywell, Hawker Beechcraft Corporation, Federal Aviation Administration, Rolls Royce Corporation - NTSB case key (mKey): 85269 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN13FA006 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/85269/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=85269 - Page: https://openairdocs.org/ntsb/CEN13FA006 ## Probable cause The pilot's loss of airplane control while maneuvering in instrument meteorological conditions. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech A36, 43 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1151604), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Communication (organizational): between groups/organizations](https://openairdocs.org/ntsb-findings/04025020): Organizational issues › Management · ATC (probable cause); cases with it: [Beech A36, 1 case](https://openairdocs.org/ntsb-findings/04025020/cases.md?model=1151604), [All aircraft, 12 cases](https://openairdocs.org/ntsb-findings/04025020/cases.md) - [Ceiling/visibility/precip: low ceiling](https://openairdocs.org/ntsb-findings/03035010): Environmental issues › Conditions/weather/phenomena · Contributed to outcome; cases with it: [Beech A36, 9 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md?model=1151604), [All aircraft, 190 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md) - [Planning/preparation: weather planning](https://openairdocs.org/ntsb-findings/02061020): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech A36, 3 cases](https://openairdocs.org/ntsb-findings/02061020/cases.md?model=1151604), [All aircraft, 156 cases](https://openairdocs.org/ntsb-findings/02061020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Beech A36, 31 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1151604), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis The pilot obtained a weather briefing the day before the accident; however, no record was found indicating that he obtained an updated briefing on the day of the flight, which would have included weather advisories for instrument meteorological conditions (IMC) surrounding the airplane's route of flight. After encountering low clouds at the destination airport, the pilot requested a clearance to divert to another nearby airport, and he was provided the clearance. No further radio transmissions were received. The airplane crashed between the two airports. Photographs of the flight conditions taken by a pilot flying in the area about the time of the accident showed low, overcast clouds above the airplane. A review of logbook entries and mechanic's statements did not reveal any unresolved maintenance or airworthiness issues. A postaccident examination of the wreckage revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. Propeller and internal engine components exhibited damage consistent with the production of power at the time of the accident. Therefore, on the basis of the evidence, the pilot most likely lost control of the airplane while maneuvering in IMC. ## Factual narrative N32GP, a 1985-model Beech A36, serial number E-2230, was a low wing, single-engine, six-place monoplane, which had retractable tricycle landing gear. According to FAA airworthiness records, the airplane was powered by a Rolls Royce 250-B17C turbine engine, which was installed in accordance with a Soloy Conversions, Ltd., supplemental type certificate SA3523NM. The installation was approved on a major repair and alteration form dated July 3, 1986. The engine drove a Hartzell, three-bladed, all-metal, constant-speed propeller. An airplane logbook endorsement indicated the airplane had its last annual inspection completed on December 13, 2011. At that time, the airplane had accumulated 2,451.8 hours of total time and the engine accumulated 854 hours of total time. That endorsement entry also indicated that the engine accumulated 205.6 hours since overhaul and 205 cycles since overhaul. A review of logbook entries and mechanic's statements did not reveal any unresolved maintenance or airworthiness issues. On October 6, 2012, about 0945 central daylight time, a Beech A36 airplane, N32GP, impacted terrain during a descent near Mabank, Texas. The pilot, pilot rated passenger and two other passengers were fatally injured. The airplane's airframe and engine were destroyed. The airplane was registered to and operated by Palm-L Aviation LLC under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Instrument flight rules conditions (IFR) conditions prevailed for the flight, which operated on an activated IFR flight plan. The flight originated from the Northwest Regional Airport (52F), near Roanoke, Texas, about 0845, and was destined for the Athens Municipal Airport (F44), near Athens, Texas. The pilot obtained a Direct User Access Terminal Service weather briefing at 1526 on the afternoon prior to the flight. There were no records of any updated briefings on the morning of the flight. The airplane was based at 52F and witnesses saw the airplane depart from there between 0830 and 0900. According to a copy of the pilot's flight plan, the listed route of flight was direct from 52F to F44 and no alternate airport was entered. The listed departure airport, 52F, did not have Jet-A fuel service. However, both F44 and the Terrell Municipal Airport (TRL), near Terrell, Texas, have services that dispense Jet-A fuel. An IFR flight plan from F44 to the Fletcher Field Airport, near Clarksdale, Mississippi, was also on file. According to air traffic control (ATC) information received from the Federal Aviation Administration (FAA), the flight encountered low clouds at F44 and requested a clearance to TRL. The flight was provided the clearance to TRL and subsequently given a frequency change. The FAA's last reported radar return from the airplane was at 0944:23 at a pressure altitude of 2,900 feet. No further radio transmissions were received. An autopsy was performed on the pilot at the Southwestern Institute of Forensic Sciences at Dallas.The cause of death was listed as blunt force injuries. The FAA Civil Aerospace Medical Institute prepared a Final Forensic Toxicology Accident Report on the pilot. The report was negative for the tests performed. The National Weather Service had issued an Airman's Meteorological Information advisory that was current at the time period of the accident for IFR conditions in the area surrounding the flight. At 0953, about 324 degrees and 17 miles from the accident site, the recorded weather at TRL was: wind 020 degrees at 10 knots; visibility 10 statute miles; overcast clouds at 600 feet; temperature 12 degrees C; dew point 9 degrees C; altimeter 30.16 inches of mercury. At 0935, about 149 degrees and 23 miles from the accident site, the recorded weather at F44 was: wind 020 at 7 knots; visibility 3 statute miles; present weather mist; sky condition overcast clouds at 500 feet; temperature 14 degrees C; dew point 13 degrees C; altimeter 30.12 inches of mercury. A pilot who was flying in the area about 15 nautical miles northeast of the accident site took pictures of the flight conditions present about 0950. The images exhibited low overcast clouds above the airplane. The pilot's images are attached to the docket material associated with this case. The pilot held a private pilot certificate, with an airplane single-engine land and instrument airplane ratings. The pilot's most recent FAA third-class medical certificate was issued on August 31, 2011. The medical certificate had a limitation for corrective lenses. At that time, he reported that he had accumulated 340 hours of total flight time and had accumulated no flight time during the six months prior to that application. The pilot recorded in his logbook that he had accumulated 568.5 hours of total flight time and had accumulated 219.5 hours in turbine-powered airplanes. An endorsement, dated May 18, 2012, indicated that the pilot had completed the training required for operating pressurized aircraft. Another endorsement, dated February 16, 2012, indicated that the pilot satisfactorily completed an instrument proficiency check. An endorsement for a current flight review was not located in the pilot's logbook. The pilot-rated passenger held a private pilot certificate with a single-engine land rating. His most recent FAA third-class medical certificate was issued on April 26, 2012. The medical certificate had a limitation for corrective lenses. At that time, he reported that he had accumulated 130 hours of total flight time and had accumulated no flight time during the six months prior to that application. Annunciator Panels Two annunciator panels were retained and subsequently examined by a Chemist in the National Transportation Safety Board (NTSB) Materials Laboratory. The report showed that the filaments exhibited inconclusive findings. The report is appended to the docket material associated with this case. Search and Rescue Actions According to a NTSB National Resource Analyst, radio and radarcontact with the aircraft was lost at 0944. The FAA issued an alert notice reporting loss of contact at 1022. The Air Force Rescue Coordination Center opened a search mission and engaged a Civil Air Patrol (CAP) radar analyst at 1135. The CAP analyst reported an initial radar position at 1319, but the analyst did not have access to all of the FAA radar data. In particular, the analyst did not have access to information from the airport surveillance radar located at Sachse, Texas, the closest radar site to the aircraft. Consequently, the initial position provided to search teams was incorrect. At 1834, the CAP informed the rescue coordination center that, based on radar data, "...they have strong reason to believe that the aircraft is within the area of Terrell, Texas..." and that CAP aircraft and ground teams were headed to the Terrell area. At about 1630, after being notified by the Investigator in Charge that the aircraft was still missing, an NTSB radar analyst joined a teleconference involving FAA personnel from Fort Worth Air Route Traffic Control Center, Fort Worth Approach Control, the Central Service Area Quality Control Group, and headquarters staff from the FAA Compliance Services group, who provide search and rescue support assistance to local ATC facilities upon request. When it became apparent that neither the FAA or the CAP had been able to review the Sachse radar site's data, the NTSB analyst asked to obtain the file. The radar file was provided by Fort Worth approach control at 1942. The NTSB analyst reviewed the information and determined a last known position for the missing aircraft by 1956. The information was provided to Fort Worth Center at 2008 for relay to a sheriff's helicopter involved in the search, and the wreckage was located about 2025 within 0.2 nautical miles of the last known position provided by the NTSB, which was approximately 10 miles southeast of the area being searched by CAP based on their earlier radar assessment not using Sachse data. The airplane impacted a field about one-half nautical mile east of the intersection of Farm to Market Road 90 and Van Zandt County Road 2702. A debris path started at an egg-shaped impact depression that was about 12 feet long and about two feet deep. The wreckage path continued on an observed heading of about 300 degrees and extended about 200 feet. The airplane was fragmented along this path with a section of the fuselage coming to rest about 95 feet from the start of the depression and the engine coming to rest about 190 feet from the start of the depression. All major components of the airplane were accounted for at the accident site. All flight control cables were traced. All observed control cable separations had a broom straw appearance consistent with overload. The left and right wing flap jackscrew actuator measurements corresponded to a zero degree flap setting. The aileron trim actuator measurement was consistent with a neutral setting. The landing gear linkageposition was consistent with retracted landing gear. The engine separated from the airframe. Debris, consistent with ingested dirt, was found in the engine's compressor section. Fuel was found in the fuel pump filter bowl. The fuel shutoff valve handle was separated from its valve housing and light could be seen through a valve housing end when a flashlight illuminated the other end. The propeller was separated from the engine. Two propeller blades remained attached to their hub and they exhibited chordwise abrasions. The separated blade exhibited S-shaped bending and chordwise abrasion. Both vacuum pumps were disassembled and their rotors exhibited impact damage. All vanes in both pumps were intact. The attitude indicator was disassembled and its gyro and cage exhibited rotational scoring. The emergency locator beacon was found within the wreckage debris and it was crushed. Due to impact damage, the total fuel on board the airplane at the time of the accident could not be confirmed. ## Aircraft - Registration: [N32GP](https://openairdocs.org/deregistered/N32GP-2018-01-03), registration cancelled 2018-01-03, S/N E-2230, built 1985 (OpenAirDocs) - Reported make and model: BEECH A36 - 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: E-2230 - Airframe hours: 2452 - Engines: Rolls Royce 250-B17C turbo prop - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Palm-L Aviation LLC - Registered owner: Palm-L Aviation LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 13, 2011 - Departed: 52F, Roanoke, TX - Destination: Athens, TX - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 569 total ## Weather - Conditions: Instrument (IMC), Day - Wind: 20° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: 600 ft overcast - Temperature: 54 °F, dew point 48 °F - Altimeter: 30.15 inHg - Observed at: TRL, 17 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 20121006024809A](https://openairdocs.org/incident/20121006024809A), Oct 6, 2012: Beech A36, Mabank, TX, Destroyed, 4 fatal. On 10/6/12 @ 0930CST, a Beechcraft A36 airplane, N32GP, impacted terrain during a descent near Mabank, Texas. The pilot, pilot rated passenger and two other… ## Docket (25 files) The files NTSB released with the investigation on November 18, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=85269. 38.0 MB in all. - Miscellaneous - Pilot Logbook Excerpts (item 1, .PDF, 560 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392618&FileExtension=.PDF&FileName=Miscellaneous%20-%20Pilot%20Logbook%20Excerpts-Master.PDF - Miscellaneous - Airplane Logbook Excerpts (item 2, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392633&FileExtension=.PDF&FileName=Miscellaneous%20-%20Airplane%20Logbook%20Excerpts-Redacted.PDF - Meteorology 5 - Factual Summary Report (item 3, .PDF, 628 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392675&FileExtension=.PDF&FileName=Meteorology%205%20-%20Factual%20Summary%20Report-Master.PDF - Miscellaneous - Pilot Weather Report and Images (item 4, .PDF, 3 photos, 367 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392648&FileExtension=.PDF&FileName=Miscellaneous%20-%20Pilot%20Weather%20Report%20and%20Images-Redacted.PDF - Miscellaneous - Flight Plan Entered In DUATS (item 5, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40394163&FileExtension=.PDF&FileName=Miscellaneous%20-%20Flight%20Plan%20Entered%20In%20DUATS-Redacted.PDF - Retention / Release of Wreckage Form (item 6, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400114&FileExtension=.PDF&FileName=Retention%20%2F%20Release%20of%20Wreckage%20Form-Redacted.PDF - Evidence Control Form (item 7, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400118&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Redacted.PDF - Materials Laboratory 15 - Factual Report 12-150 (item 8, .PDF, 17 photos, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388098&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report%2012-150-Master.PDF - Photo - Accident Site (item 9, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390992&FileExtension=.PDF&FileName=Photo%20-%20Accident%20Site-Master.PDF - Photo - Initial Impact Point (item 10, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390993&FileExtension=.PDF&FileName=Photo%20-%20Initial%20Impact%20Point-Master.PDF - Photo - Right Wing (item 11, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390994&FileExtension=.PDF&FileName=Photo%20-%20Right%20Wing-Master.PDF - Photo - Main Wreckage (item 12, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390995&FileExtension=.PDF&FileName=Photo%20-%20Main%20Wreckage-Master.PDF - Photo - Empennage (item 13, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390996&FileExtension=.PDF&FileName=Photo%20-%20Empennage-Master.PDF - Photo - Propeller (item 14, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390997&FileExtension=.PDF&FileName=Photo%20-%20Propeller-Master.PDF - Photo - Propeller Blade (item 15, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390998&FileExtension=.PDF&FileName=Photo%20-%20Propeller%20Blade-Master.PDF - Photo - Landing Gear Linkage (item 16, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391000&FileExtension=.PDF&FileName=Photo%20-%20Landing%20Gear%20Linkage-Master.PDF - Photo - Airspeed Indicator (item 17, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390999&FileExtension=.PDF&FileName=Photo%20-%20Airspeed%20Indicator-Master.PDF - Photo - Attitude Indicator Gyro (item 18, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391001&FileExtension=.PDF&FileName=Photo%20-%20Attitude%20Indicator%20Gyro-Master.PDF - Wreckage Diagram (item 19, .PDF, 572 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392652&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Chart of Accident Area (item 20, .PDF, 305 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392651&FileExtension=.PDF&FileName=Chart%20of%20Accident%20Area-Master.PDF - Miscellaneous - Mechanic's Statement and Receipt (item 21, .PDF, 379 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392677&FileExtension=.PDF&FileName=Miscellaneous%20-%20Mechanic%27s%20Statement%20and%20Receipt-Redacted.PDF - Miscellaneous - Mechanic's details on tire change and comments (item 22, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392650&FileExtension=.PDF&FileName=Miscellaneous%20-%20Mechanic%27s%20details%20on%20tire%20change%20and%20comments-Redacted.PDF - Witness Statement - Takeoff (item 23, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392676&FileExtension=.PDF&FileName=Witness%20Statement%20-%20Takeoff-Redacted.PDF - Toxicological Report - Pilot (item 24, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390983&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Pilot-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 25, .PDF, 758 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390990&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.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.