CEN13LA016

NTSB accident investigation · Beech A36 · Wausau, WI · October 17, 2012

Accident · Serious injuriesLimited investigationFinal report
Date
October 17, 2012, 08:00 local (13:00 UTC)
Place
Wausau, WI
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N121VPBeech A36
Defining event
Approach-IFR final approach: Controlled flight into terr/obj (CFIT)
Weather
Instrument (IMC) · Day
Status
Completed · report March 7, 2014
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA - Milwaukee FSDO
FAA report
20121017023939A
Case key
85367

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 decision to attempt an instrument approach in meteorological conditions below approach minimums and his failure to properly execute a missed approach.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Air traffic/operating proc: missed approach procedureEnvironmental issues › Operating environment · Compliance w/ procedureBeech A36: 1 caseAll aircraft: 2 casesProbable cause
Ceiling/visibility/precip: low ceilingEnvironmental issues › Conditions/weather/phenomena · Not specifiedBeech A36: 9 casesAll aircraft: 190 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported that, during the instrument landing system approach, the destination airport's weather system was reporting conditions below approach minimums. However, he chose to attempt the approach and, if necessary, execute a missed approach and hold until conditions improved. He stated that he usually set the decision altitude and lowered the landing gear at the final approach fix and that he thought that he had accomplished this on the accident approach; however, he stated that he did not remember hearing the decision altitude aural warning. He added that, when he was preparing the airplane for a missed approach, he saw the hills and trees, which the airplane then impacted. The pilot reported no mechanical malfunctions or failures of the airplane that would have precluded normal operation.

Factual narrative

On October 17, 2012, about 0800 central daylight time, a Beech model A36 airplane, N121VP, sustained substantial damage when it impacted trees and terrain short of the runway during an instrument approach to runway 12 at the Wausau Downtown Airport (AUW), Wausau, Wisconsin. The pilot received serious injuries. The aircraft was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a business flight. Instrument meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The flight originated from The Waukesha County Airport (UES), Waukesha, Wisconsin, about 0720. The pilot reported that as he neared AUW, the airport automated weather observing system was reporting conditions that were below approach minimums. He stated that he thought the early morning fog would be clearing, decided to attempt the approach, and if necessary perform a missed approach and hold until conditions improved. His written report indicated that he attempted an instrument landing system approach to runway 12. As he descended there was considerable glare reflecting off the tops of the low cloud layer below. Once he had descended into the clouds it became very dark and very turbulent. He stated that his usual practice was to set the decision altitude (DA) and lower the landing gear at the final approach fix. He stated that he believed that he accomplished this on the accident approach. He stated that he did not remember hearing the aural DA warning. He decided to execute a missed approach and began to configure the airplane. He then saw the hills and trees immediately prior to impact. In his written report, the pilot indicated that there were no mechanical malfunctions or failures of the airplane. No mention was made regarding instrumentation failure or anomalies related to the instrumentation or avionics within the airplane.

Aircraft

Registration
N121VP
Reported as
Beech A36
Category
Airplane
Serial number
E-937
Airframe hours
3,750
Engine
Cont Motor IO 550 SERIES, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 1, 2011
Departed
UES · Waukesha, WI
Destination
AUW · Wausau, WI
Flight plan
IFR
Airport
AUW · Wausau Downtown Airport, runway 12, 5,198 × 100 ft, asphalt

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
62
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
April 23, 2012
Seat
Left
Flight hours
1,167 total · 200 in this make and model · 1,113 as pilot in command · 50 in the last 90 days · 12 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
120° at 4 knots
Visibility
1 statute miles
Lowest ceiling
200 ft overcast
Temperature
46 °F, dew point 46 °F
Altimeter
29.36 inHg
Observed at
AUW

Docket · 1

The files NTSB released with the investigation on January 16, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 526 KB 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.