# NTSB CEN13LA016: Beech A36, N121VP, Wausau, WI, October 17, 2012 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: October 17, 2012, 08:00 local (13:00 UTC) - Place: Wausau, WI - Coordinates: 44.926387, -89.626945 - Nearby events: https://openairdocs.org/map.md?lat=44.9264&lon=-89.6269&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR final approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report March 7, 2014 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA - Milwaukee FSDO - NTSB case key (mKey): 85367 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN13LA016 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/85367/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=85367 - Page: https://openairdocs.org/ntsb/CEN13LA016 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech A36, 27 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1151604), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Air traffic/operating proc: missed approach procedure](https://openairdocs.org/ntsb-findings/03014045): Environmental issues › Operating environment · Compliance w/ procedure (probable cause); cases with it: [Beech A36, 1 case](https://openairdocs.org/ntsb-findings/03014045/cases.md?model=1151604), [All aircraft, 2 cases](https://openairdocs.org/ntsb-findings/03014045/cases.md) - [Ceiling/visibility/precip: low ceiling](https://openairdocs.org/ntsb-findings/03035010): Environmental issues › Conditions/weather/phenomena · Not specified; 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) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR final approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Beech A36, 10 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=1151604), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## 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](https://openairdocs.org/deregistered/N121VP-2014-09-03), registration cancelled 2014-09-03, S/N E-937, built 1976 (OpenAirDocs) - Reported make and model: BEECH A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-937 - Airframe hours: 3750 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: serious; 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 ## 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 20121017023939A](https://openairdocs.org/incident/20121017023939A), Oct 17, 2012: Beech A36, Wausau, WI, Substantial damage. On October 17, 2012 at 7:57 minnepolis center lost contact with the pilot of N121VP as he was cleared for a GPS approach to runway 12 auw, Wausau, WI. The… ## Docket (1 files) The files NTSB released with the investigation on January 16, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=85367. 526 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 526 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40406366&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-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.