CEN20FA019

NTSB accident investigation · Raytheon A36 · San Marcos, TX · November 20, 2019

Accident · FatalClass 3 · FieldFinal report
Date
November 20, 2019, 06:00 local (12:00 UTC)
Place
San Marcos, TX
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N88855Raytheon A36
Defining event
Initial climb: Loss of control in flight
Weather
Instrument (IMC) · Dawn
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Textron Aviation, FAA FSDO, Continental Engines
FAA report
20191120021409A
Case key
100592

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot’s loss of control shortly after takeoff in instrument meteorological conditions for reasons that could not be determined based on the available information.

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.

Not determinedNot determined › Not determined · Unknown/Not determinedRaytheon A36: 2 casesAll aircraft: 2,247 casesProbable cause
Personnel issuesPersonnel issues › Action/decision · PilotRaytheon A36: 1 caseAll aircraft: 56 casesProbable cause
Ceiling/visibility/precip: low visibilityEnvironmental issues › Conditions/weather/phenomena · Not specifiedRaytheon A36: 2 casesAll aircraft: 175 casesProbable cause

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 filed an instrument flight rules flight plan for the cross-country flight and received a departure clearance. A witness reported seeing the accident airplane taxi by his hangar before it departed and noted that the visibility at the time was less than the 1/4-mile reported by the airport’s weather observation facility. The airplane departed and was seen on radar before contact was lost shortly thereafter; the pilot never established radio communication with air traffic control. The airplane impacted terrain in a near-vertical attitude about 1/2-mile from the departure runway. Examination of the airplane did not reveal any pre-impact anomalies that would have precluded normal operation. Low instrument flight rules conditions prevailed in the area of the departure airport, including a cloud ceiling of about 300 ft above ground level. The airplane’s sudden descent and near-vertical impact attitude are consistent with a loss of control shortly after takeoff; however, due to a lack of onboard data and complete radar data for the flight, the reason for the loss of control could not be determined based on the available information.

Factual narrative

On November 20, 2019, about 0600 central standard time, a Raytheon (Beechcraft) A36 airplane, N88855, was destroyed when it was involved in an accident near San Marcos, Texas. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. The pilot filed an instrument flight rules flight plan and was issued a clearance for departure, but the pilot did not make contact with air traffic control after takeoff, nor did he transmit any distress calls. The airplane was observed on radar after departure, but radar contact was lost shortly thereafter. A witness reported that he saw the airplane taxi by his hangar before it departed. He stated that the airport’s weather observing station was reporting an overcast ceiling 300 ft above ground level and 1/4-mile visibility at the time. He stated that the visibility was less than reported, adding that he could barely see the accident airplane near the runway because the weather was so poor. The witness reported that the engine sounded “normal” and that the engine rpm increased, so he assumed that the airplane departed. The wreckage was located about ½ mile northeast of the departure runway. The Central Texas Autopsy, PLLC, Lockhart, Texas, under the authority of the Justice of the Peace, Caldwell County, conducted an autopsy on the pilot. The cause of death was determined to be "multiple traumatic injuries.” The Federal Aviation Administration’s (FAA) Forensic Sciences Laboratory conducted toxicological testing on the pilot. Tests were negative for ethanol and tested-for drugs. At 0556, the automated weather facility located at HYI recorded wind from 179° degrees at 4 knots, 1/2-mile visibility in fog, an overcast cloud ceiling at 300 ft above ground level, temperature 63°F, and dew point 63°F. The pilot accessed weather information through ForeFlight the night before the accident and again about one hour before departure. The information provided included a forecast for continued low instrument flight rules (LIFR) conditions through the morning of the accident. Additional weather information is included in the public docket for this accident. The pilot was issued a temporary airman’s certificate on November 12, 2019, for Second-in-Command (SIC) privileges for a Cessna 650. A review of the pilot’s resume revealed 81 total hours of instrument experience (actual and simulated). The airplane impacted terrain in a firearm target practice area. The entire wingspan displayed accordion-like crush damage. The cabin area was crushed and the engine was buried in the ground. Airplane damage and ground scars were consistent with a near-vertical impact attitude. There was no post-crash fire. Control continuity was partially established from the cockpit to the corresponding flight control surfaces through multiple cuts made by first responders. The landing gear was retracted and the flap actuator was extended about 1 3/8 inches, which corresponded to aflaps-retracted position. The wing fuel tank bladders were ruptured and the fuel selector was on the right fuel tank position. Residual fuel was consistent with 100LL aviation fuel and did not contain water. The airplane was equipped with a standby instrument air pump driven by an electric motor. The pump was separated from the electric motor and disassembled. The carbon rotor and vanes were impact damaged. The drive coupling was intact. The engine-driven instrument air pump remained attached to the engine. The pump was removed, and the drive coupling was found intact. The carbon rotor and vanes were impact damaged. All fracture edges were sharp, and the broken pieces remained tightly together. The engine displayed significant impact damage, and the crankshaft could not be rotated by hand. Internal engine components were observed through use of a borescope. The rocker covers were removed, and no discrepancies were noted with the valve train and accessory section. The two magnetos were removed and rotated by hand; spark was observed from each top ignition lead. The engine-driven fuel pump was intact and the drive shaft rotated, with some binding, when operated by hand. The top set of sparkplugs exhibited normal-colored combustion deposits and “worn out-normal” electrodes when compared to the Champion Check-a-Plug guide. The fuel throttle body and mixture control were recovered and examined. The throttle plate was in the “full” open position. All control arms remained attached to corresponding shafts and attaching hardware was intact. The fuel screen was removed and was free of debris. The propeller separated from the crankshaft flange; two of the three propeller blades remained in the propeller hub; the third bladed separated from the hub. All three blades exhibited leading edge gouging and twisting.

Aircraft

Registration
N88855
Reported as
Raytheon A36
Category
Airplane
Serial number
E-3239
Built
1999
Airframe hours
3,086.5
Engine
Continental IO-550, reciprocating
Damage
Destroyed
Flight
Business · Part 91
Operator
Caroline Aviation Llc
Registered owner
Caroline Aviation Llc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 28, 2019
Departed
KHYI · San Marcos, TX
Destination
KODO · Odessa, TX
Flight plan
IFR
Airport
KHYI · San Marcos, runway 8, 6,330 × 100 ft, asphalt
Equipment
ADS-B

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
48
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
605 total

Weather

Conditions
Instrument (IMC) · Dawn
Wind
170° at 4 knots
Visibility
0.5 statute miles
Lowest ceiling
300 ft overcast
Temperature
63 °F, dew point 63 °F
Altimeter
29.96 inHg
Observed at
KHYI

Docket · 15

The files NTSB released with the investigation on August 5, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 47.5 MB 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.