DEN07FA071

NTSB accident investigation · Beech A23A · Holman, NM · March 13, 2007

Accident · FatalField investigationFinal report
Date
March 13, 2007, 15:30 local (21:30 UTC)
Place
Holman, NM
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N4761JBeech A23A
Weather
Visual (VMC) · Day
Status
Completed · report July 25, 2007
Report
Approved by Office Director
Parties
FAA Flight Standards District Office, Teledyne Continental Motors, Raytheon Aircraft Corporation
FAA report
20070313002959A
Case key
65459

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 failure to maintain a safe altitude and clearance, and his improper inflight planning/decision to postpone initiating a climbing turn to avoid obstructions.

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 collision with objectManeuvering - turn to reverse direction
Altitude/clearance - not maintainedPilot in commandCause
In-flight planning/decision - improperPilot in commandCause
Altitude - low
Object - tree(s)
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - mountainous/hilly

Analysis

The airplane struck a grove of trees and impacted terrain in a near-vertical attitude, just below a state highway, at the 9,186-foot level. Two witnesses reported seeing a low-flying airplane that was "barely clearing the trees." One of the witnesses said the airplane's wheels were about "20 to 50 feet above the trees" and the airplane banked south. They lost sight of the airplane as he rounded a bend in the road. According to the pilot's flight instructor, the pilot and he had flown this route numerous times. Both the pilot and the instructor were familiar with the terrain and the mountain pass. According to the Albuquerque Sectional Chart, the summit of the pass is approximately 10,000 feet msl. Engine disassembly revealed no discrepancies. Data downloaded from a Garmin GPS (Global Positioning System) MAP 195 recovered from the wreckage revealed the airplane had been cruising between 100 and 125 mph. According to NTSB's GPS Specialist's factual report, "The airplane began to slow gradually after passing over Rt. 518. This road lies in the center of a broad north-south oriented valley. The airplane had slowed to approximately 74 mph by the time it reached the coordinates of the last recorded GPS tracklog point. The airplane maintained a near straight line course during this time" and was "entering an area of rising terrain. Information concerning aircraft altitude was not available because the GPSMAP 195 does not calculate and record GPS altitude."

Factual narrative

History of flight

On March 13, 2007, approximately 1530 mountain daylight time*, a Beech A23A, N4761J, piloted by a commercial pilot, was destroyed when it struck trees and impacted terrain one mile northwest of Holman, New Mexico. Visual meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 CFR Part 91, and a visual flight rules (VFR) flight plan had been filed and activated. The pilot, the sole occupant on board, was fatally injured. The cross-country flight originated at Northwest Regional Airport (52F), Roanoke, Texas, at 1036 CDT. The airplane refueled at Tucumcari, New Mexico, and was en route to Animas Airpark (00C), Durango, Colorado.

According to his sister, the pilot, a college physics professor, was en route to Durango --- a trip he had made many times previously --- to check on some property that he owned there. He was also planning to visit friends and his alma mater, Fort Lewis College.

The following is based on data downloaded from a GPS (Global Positioning System) found aboard the airplane; FAA documents and radar data; witness reports; a New Mexico State Police report, and other documents.

At 0934 on the morning of the accident, the pilot purchased 40.08 gallons of fuel and departed 52F at 1036 CDT. He reported TCC in sight at 1313 and landed at 1318. He purchased 26.7 gallons of fuel at 1403. While the airplane was being serviced, the pilot obtained an abbreviated weather briefing from the Albuquerque Automated Flight Service Station. The airplane departed TCC at 1422, and struck trees and terrain at 1530:28. When the pilot failed to close his flight plan, FAA issued an Alert Notice (ALNOT) at 1924.

Two witnesses, traveling southeast on N.M. Route 518 near Old Holman Road, saw a low-flying airplane that was "barely clearing the trees." Contacted by telephone, one witness said the airplane's wheels were about "20 to 50 feet above the trees" and the airplane banked south. He lost sight of the airplane as he rounded a bend in the road.

The search area was originally in the Chacon area on N.M. Route 121 near milepost 5. When the witnesses learned that an airplane was missing in the area, they contacted authorities and reported what they had seen and the location. Based on this new information and homing on ELT (emergency locator transmitter) signals, a New Mexico State Police (NMSP) helicopter located the wreckage the next morning at 1049. The accident site was located next to N.M. Route 518 at milepost 41.5.

According to the pilot's flight instructor, the pilot and he had flown this route numerous times. Both the pilot and the instructor were familiar with the terrain and the mountain pass.

The accident occurred during the hours of daylight at a location of 36 degrees, 04.82 minutes North latitude, and 105 degrees, 26.23 minutes West longitude.

Personnel information

The pilot, age 61, held a commercial pilot certificate with airplane single/multiengine and instrument ratings. He also held a second-class airman medical certificate, dated January 6, 2006, with the restriction, "Must wear corrective lenses."

Logbook 2, containing entries from July 22, 1995, to February 23, 2007, revealed the pilot had accrued the following flight time:

Total Time: 1,625.0

Pilot-in-Command: 1,387.8

Beech A23A: 1,398.1

Single-Engine, Land: 1,522.0

Multiengine, Land: 60.2

Cross-Country: 835.8

Actual Instruments: 35.1

Simulated Instruments: 190.5

Night: 132.3

Flight reviews were recorded on April 14 and October 26, 2006. Both were taken in N4761J.

Aircraft information

Beech Aircraft Corporation manufactured N4761J (s.n. M-1022), a model A23A, in 1967. A Continental IO-346-A engine (s.n. 100507-6-A), rated at 165 horsepower at 2,700 rpm, powered the airplane, driving a Sensenich 2-blade, all-metal, fixed pitch propeller (m.n. M74DC-0-60).

According to the maintenance records, the engine and propeller were overhauled on February 17, 2004, at a tachometer time of 1955.8, and a total time of 4,010.8 hours. The last annual/100-hour inspection was on April 6, 2006, at a tachometer time of 2,092.6, and a total time of 4,147.6 hours, and 136.8 hours had elapsed since major overhaul. The airplane was last certified for IFR operations on May 26, 2006, at a tachometer time of 2,097:99 when the altimeter, static system and transponder were tested to 20,000 feet. The last weight and balance was dated September 7, 1991. At that time, the empty weight was 1,453 pounds, the gross weight was 2,400 pounds, and the useful load was 947 pounds. The empty weight center of gravity was calculated to be +111.09 inches aft of datum.

Meteorological information

The Las Vegas (LVS), New Mexico, ASOS (Automated Surface Observing System, located approximately 36 miles southeast of the accident site, recorded the following METARs (Aviation Routine Weather Reports):

(1453): Wind, variable at 3 knots; visibility, 10 statute miles (or greater); sky condition, clear; temperature, 17 degrees Celsius (C); dew point, -9 degrees C.; altimeter, 30.01 inches of Mercury; remarks: sea level pressure, 1098 millibars.

(1553): Wind, variable at 5 knots; visibility, 10 statute miles (or greater); sky condition, clear; temperature, 19 degrees C.; dew point, -11 degrees C.; altimeter, 29.99 inches of Mercury; remarks: sea level pressure, 1095 millibars.

Wreckage and impact information

Just above the accident site, Highway 518 was at a GPS elevation of 9,226 feet. The airplane struck a grove of trees and impacted terrain in a near-vertical attitude at the 9,186-foot level. According to the Albuquerque Sectional Chart, the summit of the pass is approximately 10,000 feet msl.

The distance between the first tree strike and the wreckage was 46 feet. Control continuity was established. Propeller and spinner examination revealed signatures consistent with little or no rotation.

Cockpit examination revealed the following readings:

Airspeed Indicator: 0

Artificial Horizon: Wings level

Altimeter: 11,000 feet

Kollsman Window: 29.94 in. Hg.

Turn Coordinator: Level, Full Left Ball

Wet Compass: 070 degrees

Ammeter: 0

Suction: 0

Exhaust Gas Temperature: 0

Right Fuel: ¼ Full

Left Fuel: Destroyed

Fuel Pressure: 0

Fuel Boost: On

Tachometer: 0

Magnetos: Both

Hour Recorder: 2,153:18

Master (BATT/ALT): On

No. 1 OBS: 275 degrees

No. 2 OBS: 245 degrees

No. 1 NAV: Digital

No. 2 NAV: 117.6 mHz

No. 1 COMM: Digital

No. 2 COMM: 122.7 mHz

Transponder: 1200 (mode C)

ADF: 190-430 kHz (on)

Bearing: 101 degrees

Throttle: Full In

Mixture: ½" Out

Cabin Heat: Off

Cabin Air: Off

Defrost: Off

Avionics Master: Off

Landing Gear: Up

Flaps: Up

Pitot Heat: Destroyed

Rotating Beacon: On

Landing Lights: Undetermined

Position Light: Undetermined

Medical and pathological information

An autopsy (#2007-02048) was performed by the New Mexico Medical Examiner's Office in Albuquerque. FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, and the New Mexico Medical Examiner's Office performed toxicological protocol. In both cases, no carbon monoxide, cyanide, ethanol, or drugs were detected.

Tests and research

On April 17, 2007, the engine and various accessories were disassembled and examined at Air Transport in Phoenix, Arizona. No discrepancies, other than impact damage, were noted.

A Garmin GPS (Global Positioning System) MAP 195 was recovered from the wreckage and sent to NTSB's Vehicle Recorder Laboratory in Washington, DC, for download and readout. Recorded data began at 1417:56, and ended at 1530:28. According to NTSB's GPS Specialist's report, the airplane's had been cruising "between 100 and 125 mph" until approximately 1526. "The airplane began to slow gradually below 115 mph groundspeed after passing over Rt. 518. The road li

Aircraft

Registration
N4761J
Reported as
Beech A23A
Category
Airplane
Serial number
M-1022
Airframe hours
2,153
Engine
Continental IO-346-A, 165 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Azusa, Llp
Registered owner
Azusa, Llp
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · April 1, 2006 · 61 hours before
Departed
TCC · Tucumcari, NM
Destination
00C · Durango, CO
Flight plan
VFR

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
61
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
October 1, 2006
Seat
Left
Toxicology
Performed
Flight hours
1,625 total · 1,605 in this make and model · 1,365 as pilot in command · 5 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 16 °F
Altimeter
30.01 inHg
Observed at
LVS, 32 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.