# NTSB CEN20FA019: Raytheon A36, N88855, San Marcos, TX, November 20, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: November 20, 2019, 06:00 local (12:00 UTC) - Place: San Marcos, TX - Coordinates: 29.899999, -97.8525 - Nearby events: https://openairdocs.org/map.md?lat=29.9000&lon=-97.8525&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Textron Aviation, FAA FSDO, Continental Engines - NTSB case key (mKey): 100592 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20FA019 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100592/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100592 - Page: https://openairdocs.org/ntsb/CEN20FA019 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Raytheon A36, 2 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=7150001), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) - [Personnel issues](https://openairdocs.org/ntsb-findings/02040000): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Raytheon A36, 1 case](https://openairdocs.org/ntsb-findings/02040000/cases.md?model=7150001), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/02040000/cases.md) - [Ceiling/visibility/precip: low visibility](https://openairdocs.org/ntsb-findings/03035015): Environmental issues › Conditions/weather/phenomena · Not specified (probable cause); cases with it: [Raytheon A36, 2 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md?model=7150001), [All aircraft, 175 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Raytheon A36, 6 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7150001), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Initial climb: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Raytheon A36, 17 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7150001), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Uncontrolled descent: Unknown or undetermined](https://openairdocs.org/ntsb-events/000); cases with it: [Raytheon A36, 2 cases](https://openairdocs.org/ntsb-events/000/sequence.md?model=7150001), [All aircraft, 1,703 cases](https://openairdocs.org/ntsb-events/000/sequence.md) ## 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](https://openairdocs.org/deregistered/N88855-2021-10-30), registration cancelled 2021-10-30, S/N E-3239, built 1999 (OpenAirDocs) - Reported make and model: RAYTHEON A36 - Registry model: [Raytheon A36](https://openairdocs.org/model/raytheon-a36) (registry code 7150001) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-3239 - Year built: 1999 - Airframe hours: 3086.5 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; injuries: fatal; 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 ## 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 20191120021409A](https://openairdocs.org/incident/20191120021409A), Nov 20, 2019: Raytheon Aircraft Company A36, San Marcos, TX, Destroyed, 1 fatal. N88855 a Beech bonanza A-36 departed on an IFR flight from San Marcos airport destined for odesa, Texas. The aircraft was provided an IFR release from khyi… ## Docket (15 files) The files NTSB released with the investigation on August 5, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100592. 47.5 MB in all. - Location (item 1, PDF, 1 page, 9.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9639567&FileExtension=pdf&FileName=Location%20overview-Rel.pdf - Weather study report (item 2, PDF, 24 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8776368&FileExtension=pdf&FileName=CEN20FA019_weatherstudySuffernfinal-Rel.pdf - Weather attachment 1 (item 3, GIF, 22.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8776550&FileExtension=gif&FileName=attachment1_animationNT_SAT_1101to1306utc_CODNEXLAB-GOES-East-subregional-Texas-ntmicro-13_06Z-20191120_map-id_-26-1n-10-100-Rel.gif - Weather attachment 2 (item 4, PDF, 5 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8776377&FileExtension=pdf&FileName=attachment2_GFAimagedata-Rel.pdf - Weather attachment 3 (item 5, PDF, 2 pages, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8776110&FileExtension=pdf&FileName=attachment3_foreflight_Redacted-Rel.pdf - Weather attachment 4 (item 6, PDF, 1 page, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8776695&FileExtension=pdf&FileName=attachtment4_foreflight2_Redacted-Rel.pdf - Weather attachment 5 (item 7, PDF, 463 pages, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8776559&FileExtension=pdf&FileName=attachment5_leidoscopyofforeflight-Rel.pdf - Engine data monitor - specialist's factual report (item 8, PDF, 5 pages, 744 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9035517&FileExtension=pdf&FileName=Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - Attachment 1 to engine data monitor - specialist's factual report (item 9, CSV, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9034988&FileExtension=csv&FileName=Attachment%201%20to%20Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report-Rel.csv - Witness statements (item 10, PDF, 1 page, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9639692&FileExtension=pdf&FileName=witness%20statement_Redacted-Rel.pdf - Maintenance records (excerpts) (item 11, PDF, 5 pages, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11636329&FileExtension=pdf&FileName=MX%20records_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 12, PDF, 1 page, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9665623&FileExtension=pdf&FileName=Wreckage%20Release_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 13, PDF, 3 pages, 843 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9640834&FileExtension=pdf&FileName=Party%20Forms_Redacted-Rel.pdf - Photos (item 14, PDF, 5 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9646408&FileExtension=pdf&FileName=Photo%201-Rel.pdf - Toxicological report (item 15, PDF, 1 page, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11673643&FileExtension=pdf&FileName=tox_Redacted-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.