CHI93FA200

NTSB accident investigation · Beech A-36 · Tony, WI · June 9, 1993

Accident · FatalField investigationFinal report
Date
June 9, 1993, 07:57 local (12:57 UTC)
Place
Tony, WI
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N236ABeech A-36
Weather
Instrument (IMC) · Day
Status
Completed · report December 2, 1994
Report
Approved by Office Director
FAA report
19930609017739A
Case key
9167

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 continue flight into known adverse weather and exceeded the design strees limits of the airplane. Factors associated with the accident were inadequate preflight planning/preparation, clouds, turbulence, icing conditions, and the lack of recent instrument experience.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight encounter with weatherCruise
Preflight planning/preparation - inadequatePilot in commandFactor
Weather condition - cloudsFactor
Weather condition - icing conditionsFactor
Weather condition - turbulence in cloudsFactor
Flight into known adverse weather - continuedPilot in commandCause
Loss of control - in flightCruise
Lack of recent instrument timePilot in commandFactor
Airframe/component/system failure/malfunctionDescent - uncontrolled
Design stress limits of aircraft - exceededPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The pilot was advised of instrument meteorological conditions and moderate turbulence along his proposed route of flight during his pre-departure weather briefing from the afss. While en route, the pilot contacted the afss requesting updated weather for his route of flight. The afss specialist advised the pilot that VFR flight was not recommended throughout the area. The pilot did not respond to the specialist's radio call. FAA center radar showed the airplane flying on a northwesterly heading at 10,400 feet MSL when the pilot called the afss. Shortly after the call, the radar data showed the airplane perform a righthand 180 degree turn and begin a descent. The last radar altitude was 7,800 feet MSL. The wreckage trail was approximately 1 1/8 mile long heading from north to south. Upper air temperatures from the goes satellite were zero degrees centigrade between 10,300 and 10,600 feet MSL. The pilot's last logged flight by reference to instruments was March 24, 1992.

Factual narrative

History of flight

On June 9, 1993, at 0757 central daylight time (cdt), a Beech A-36, N236A, registered to Flite Line Associates of Wauwatosa, Wisconsin, and piloted by an instrument rated private pilot, was destroyed when it experienced an inflight structural breakup. Instrument meteorological conditions prevailed at the time of the accident. The 14 CFR Part 91 flight was not operating on a flight plan. The pilot and passenger received fatal injuries. The flight originated from Waukesha, Wisconsin, at 0616 CDT.

The pilot of N236A contacted the Green Bay, Wisconsin, Automated Flight Service Station (AFSS) at 0500 cdt on June 9, 1993. The AFSS specialist advised the pilot that an AIRMET for IFR conditions existed along with occasional moderate turbulence below 12,000 feet along his intended route of flight. The pilot was advised of a low pressure area over north central Minnesota, which had an occluded front extending eastward into north central Wisconsin. During the weather briefing the AFSS specialist stated the weather was expected to improve by 0900 central daylight time.

The AFSS specialist continued the briefing, advising the pilot that "... quite a bit of rain still expected for northwestern Wisconsin and the northern two thirds-of Minnesota, and western Lake Superior areas but ... it's not supposed to be thunderstorms just rain." The specialist asked the pilot if he wanted the winds aloft and he responded, "Ah no I will probably call you as I after I'm airborne."

At 0704 CDT the pilot of N236A again contacted the AFSS at Green Bay, Wisconsin. The pilot requested a weather update for Duluth, Minnesota. The specialist advised the pilot that "... flight precautions for occasionally moderate turbulence below one two thousand with low level wind shear potential ... flight precautions ... for IFR conditions throughout northern Minnesota and the upper Peninsula IFR conditions are being reported in northern Minnesota VFR flight is not recommended... ."

The pilot contacted the same AFSS at 0754 CDT stating the airplane was positioned approximately 20 miles south of Hayward, Wisconsin, at an altitude of 10,500 feet mean sea level (msl). In addition to much of the same information given to the pilot during the earlier briefing, the AFSS specialist added the following to this briefing: "... live radar is depicting scattered light rain showers across ah northwestern Wisconsin... ." The pilot did not respond to this radio transmission. The specialist called the pilot's airplane "N" number at 0757 cdt with no response.

There were no further radio transmissions from N236A, nor were there witnesses to the airplane's descent and subsequent collision with the terrain.

The National Track Analysis Program (NTAP) data was generated by the Eagle River, Wisconsin, secondary radar site for the FAA's Minneapolis, Minnesota, Air Route Traffic Control Center (ARTCC). This site can provide data on transponder returns only. The data initially shows N236A on a northwest ground track followed by a right turn that resulted in a southeast ground track. The NTAP altitude readout data showed N236A maintaining an altitude of 10,400 feet msl while flying the northwest ground track up to the time of the pilot's radio call to the Green Bay, Wisconsin, FAA AFSS (0754:53 CDT). During the 2 minutes and 23 seconds of radio conversation that followed, the NTAP data shows N236A's altitude decreasing to 9,100 feet msl at 0757:12 CDT, at 0757:24 CDT the airplane's altitude is reported at 7,800 feet msl. After 0757:24 there were no other radar contacts.

Personnel information

The pilot obtained an airplane, single engine land instrument rating on July 29, 1989. At the time of issuance his logbook showed 1,308.5 hours of total flight time and 108.4 hours of instrument flying (6.1 in instrument meteorological conditions, 75.5 simulated instrument, and 26.8 hours of instrument simulator).

Pilot logbook entries between September 5, 1990, and January 4, 1991, showed the pilot flying dual instructional flights in a Beechcraft A-36. He received 34.3 hours of dual instruction in the A-36; 17.9 hours were logged as simulated instrument (hood). The last dual instruction entered in the pilot's logbook was on February 21, 1991. The logbook entry showed 1.5 hours total time, with 1.3 hours simulated instrument (hood). The last instrument reference flight made in the A-36 was on March 24, 1992, according to the pilot's logbook.

Logbook entries do not go beyond March 20, 1993. Trip sheets provided by one of the partners in N236A show the pilot's last flight, before the accident flight, was on May 20, 1993, 1.23 hours tachometer recorded time.

Aircraft information

N236A was modified according to STC SA2200SW that allowed the installation of a Continental IO-550B engine on February 28, 1992. The engine had a McCauley 3A32C76-S-M propeller installed on it at this time.

According to the co-owners of the airplane, the weight and balance paperwork and maintenance records were kept in the airplane. Pieces of the airplane maintenance records were found along the wreckage trail. N236A received an annual inspection on June 16, 1992. At the time of inspection the airplane had 1861.6 hours total time and 72.2 hours on the engine.

According to a work order received from the Waukesha Flying Service, Incorporated, of Waukesha, Wisconsin, N236A had its engine oil changed on April 23, 1993. The air frame had 1,999.47 hours total time on this date.

No other maintenance records were located or forwarded by the co-owners of the airplane.

Meteorological information

The Neenah, Wisconsin, weather radar site operated by the National Oceanic and Atmospheric Administration (NOAA) showed no precipitation for its coverage area from 0700 CDT to 1000 CDT. The 0830 and 0930 CDT NOAA weather radar, at Minneapolis, Minnesota, showed rain showers and light rain in extreme northwest Wisconsin, and north of Minneapolis, Minnesota. Precipitation in the accident site area was not depicted on either of the radar sites images.

The NTSB's Office of Aviation Safety confirms Minneapolis, Minnesota's, NOAA radar information by stating there were no radar echoes within 25 nautical miles of the accident site. Upper air data for the area in proximity to the accident site showed a temperature for the 672.0 millibar height (approximately 10,800 feet msl) was minus 0.1 degrees centigrade. The temperature at the 700 millibar height (approximately 9,800 feet msl) was plus 1.2 degrees centigrade.

According to the NOAA's Geostationary Operational Environmental Satellite (GOES) infrared images the temperatures at 10,337 and 10,604 feet msl were reported to be -0.54 and -0.96 degrees centigrade between 0831 and 0931 cdt respectively. Aviation surface weather sequence reports (SA) for Rice Lake, Wisconsin, show light drizzle and an altimeter setting of 29.39 inches of mercury at 1050 cdt. Rice Lake, Wisconsin, is approximately 35 nautical miles west-southwest from the accident site. The Phillips, Wisconsin, aviation surface weather sequence report for 0845 cdt showed surface winds from 210 degrees at 10 knots with gusts to 17 knots and an altimeter setting of 29.46 inches of mercury. Phillips, Wisconsin, is approximately 23 nautical miles east-northeast from the accident site.

Wreckage and impact information

N236A's wreckage was scattered over a 1 1/8 statue mile trail on a south-south westerly heading through dense woods and marshy terrain. An east-west running creek ("Spring Creek") cuts the wreckage trail approximately in half. Components of the right and left elevator and horizontal stabilizer and elevators were found approximately 1,200 yards north of the engine and forward fuselage assembly.

The right wing was located approximately 50 yards north of the Spring Creek. The left wing was located o

Aircraft

Registration
N236A
Reported as
Beech A-36
Category
Airplane
Serial number
E-1862
Engine
Continental IO-550B(5), 300 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Flite-Line Associates
Registered owner
Flite-Line Associates
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 16, 1992
Departed
UES · Waukesha, WI
Destination
JM8 · Ft. Francis Ont

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
66
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
1,488 total · 164 in this make and model · 1,354 as pilot in command · 28 in the last 90 days · 4 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
210° at 10 knots
Visibility
8 statute miles
Lowest ceiling
600 ft broken
Temperature
57 °F, dew point 55 °F
Altimeter
29.00 inHg
Observed at
RIE, 31 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.