# NTSB CHI90FA028: Beech A36, N1607W, Shell Lake, WI, November 14, 1989

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: November 14, 1989, 13:25 local (19:25 UTC)
- Place: Shell Lake, WI
- Coordinates: 45.729034, -91.890251 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=45.7290&lon=-91.8903&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 3 fatal
- Status: Completed, report June 30, 1992
- Report: Approved by Office Director
- NTSB case key (mKey): 14515
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI90FA028
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/14515/pdf
- Page: https://openairdocs.org/ntsb/CHI90FA028

## Probable cause

THE PILOT-IN-COMMAND'S FAILURE TO PERFORM A MISSED APPROACH, HIS DESCENDING BELOW THE MINIMUM DESCENT ALTITUDE, AND HIS FAILURE TO MAINTAIN PROPER ALTITUDE TO AVOID IMPACT WITH THE TERRAIN. CONTRIBUTING TO THE ACCIDENT WAS THE PILOT-IN-COMMAND'S LACK OF TOTAL INSTRUMENT TIME, HIS LACK OF RECENT TOTAL EXPERIENCE, AND HIS LACK OF RECENT EXPERIENCE IN THIS TYPE OF OPERATION.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- In flight collision with terrain/water, approach
  - weather condition - snow (contributing factor)
  - missed approach - not performed, pilot in command (cause)
  - lack of total instrument time, pilot in command (contributing factor)
  - terrain condition - water (contributing factor)
  - minimum descent altitude - exceeded, pilot in command (cause)
  - lack of recent total experience, pilot in command (contributing factor)
  - proper altitude - not maintained, pilot in command (cause)
  - lack of recent experience in type operation, pilot in command (contributing factor)

## Analysis

AN NDB APPROACH WAS ATTEMPTED TO AN UNCONTROLLED AIRPORT DURING MODERATE SNOW CONDITIONS. VISIBILITY WAS REPORTED RESTRICTED IN SNOW SHOWERS BY AREA RESIDENTS AT THE TIME OF THE APPROACH. THE AIRCRAFT DESCENDED INTO A LAKE ADJACENT TO THE AIRPORT AND WAS DESTROYED. THE PILOT HAD RECEIVED A WEATHER BRIEFING WHICH INCLUDED THE POSSIBILITY OF SNOW SHOWERS. THERE IS NO INDICATION THAT THE PILOT ATTEMPTED TO PERFORM A MISSED APPROACH. WITNESS REPORTS INDICATE THAT THE AIRCRAFT HAD DESCENDED BELOW THE MINIMUM DESCENT ALTITUDE PRIOR TO IMPACT. THE PILOT HAD LIMITED TOTAL INSTRUMENT EXPERIENCE, A LACK OF RECENT TOTAL EXPEREINCE AND A LACK OF RECENT EXPERIENCE IN THIS TYPE OF OPERATION.

## Aircraft

- Registration: [N1607W](https://openairdocs.org/deregistered/N1607W-1992-04-23), registration cancelled 1992-04-23, S/N E341 (OpenAirDocs)
- Reported make and model: BEECH A36
- Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs)
- Category: Airplane
- Serial number: E-341
- Airframe hours: 2204
- Engines: CONTINENTAL IO-520-BA 285 horsepower reciprocating
- Damage: Destroyed
- Flight: Business, Part 91
- Registered owner: Henry Horecki
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, May 31, 1989, 27 hours before
- Departed: FCM, MINNEAPOLIS, MN
- Destination: SSQ, SHELL LAKE, WI
- Flight plan: IFR
- Airport: SSQ, Shell Lake Muni, runway 31, 3,100 × 50 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 58; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 469 total, 302 in this make and model, 389 as pilot in command, 13 in the last 90 days, 1 in the last 30 days, 1 in the last 24 hours

## Weather

- Conditions: Instrument (IMC), Day
- Wind: 50° at 10 knots
- Temperature: 36 °F, dew point 28 °F
- Altimeter: 29.00 inHg
- Observed at: RIE, 20 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 19891114051059A](https://openairdocs.org/incident/19891114051059A), Nov 14, 1989: Beech A36, Shell Lake, WI, Destroyed, 3 fatal. High speed water impact indicates loss of control during adf approach, snow showers in area. Lacked recent IFR.

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.

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