# NTSB ERA13FA349: Beech A36, N1831W, Alma, GA, August 4, 2013 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: August 4, 2013, 11:55 local (15:55 UTC) - Place: Alma, GA - Coordinates: 31.642221, -82.609725 - Nearby events: https://openairdocs.org/map.md?lat=31.6422&lon=-82.6097&mi=10 - Phase of flight: [Unknown](https://openairdocs.org/ntsb-phases/990) (OpenAirDocs' grouping) - Defining event: [Unknown: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report December 10, 2014 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Beechcraft, FAA/FSDO, Continental Motors Inc. - NTSB case key (mKey): 87660 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA13FA349 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/87660/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=87660 - Page: https://openairdocs.org/ntsb/ERA13FA349 ## Probable cause Descent from cruise flight until impact with trees and the ground for reasons that could not be determined because postaccident examination of the wreckage did not reveal any anomalies that would have precluded normal operation and the pilot's autopsy and toxicology tests did not provide any evidence of impairment or incapacitation. ## 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: [Beech A36, 23 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=1151604), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Unknown or undetermined](https://openairdocs.org/ntsb-events/000); cases with it: [Beech A36, 11 cases](https://openairdocs.org/ntsb-events/000/sequence.md?model=1151604), [All aircraft, 1,703 cases](https://openairdocs.org/ntsb-events/000/sequence.md) - [Unknown: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Beech A36, 10 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=1151604), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis The pilot was flying the airplane on a cross-country flight to his home airport in day visual meteorological conditions. While in cruise flight at 5,000 feet mean sea level (msl), the airplane began descending and was lost from radar at 2,800 feet msl, 2 miles from the accident site. The pilot did not transmit any distress calls to air traffic control. Witnesses near the accident site heard the airplane with the engine operating then shortly thereafter heard the sound of impact. Examination of the accident site indicated that the airplane had flown through trees at a shallow angle and impacted the ground on a road. Postaccident examination of the airframe and engine revealed no indications of preimpact anomalies; all observed damage was consistent with ground impact. Postmortem examination of the pilot indicated that the cause of death was multiple blunt force injuries. The pilot's toxicology testing revealed medications that were unlikely to have contributed to the accident. Testing for carbon monoxide could not be performed due to unsuitable samples. A postmortem examination and toxicology tests were not performed on the passenger. It could not be determined why the flight gradually descended from cruise altitude until impact with trees and the ground. ## Factual narrative Portable Global Positioning System A Garmin 696 portable global positioning system was located in the wreckage and sent to the NTSB Vehicle Recorders Laboratory for download. The data downloaded was for dates prior to the accident date and did not reveal any pertinent information regarding the accident flight. According to FAA records, the airplane was issued an airworthiness certificate in 1973 and was registered to APS Aviation LLC on March 18, 2010. It was equipped with a Continental Motors IO-550-B(4) series, serial number 249169-R, 300-hp engine. It was also equipped with a McCauley propeller. The airplane's most recent annual inspection could not be documented due to the inability to locate the records at the time of this writing. A flight log form found at the accident site noted "Annual," dated July 8, 2013, at the tach time of 2764.9 hours. The most recent recorded fueling was accomplished on August 4, 2013 at FHB. The airplane had been fueled with a total of 20 gallons of fuel; 10 gallons of fuel in each main fuel tank. A review of voice recordings provided by Jacksonville Air Traffic Control Tower (JAX) revealed no indication from the airplane of any anomalies. A radar hand-off was accomplished between JAX to Jacksonville ARTCC (ZJX). The accident flight contacted ZJK at 1127 and was issued the current altimeter setting. Then, at 1151, while en route at 5,000 feet mean sea level, the radar data tag for the accident airplane went into to a coast mode. The radar controller attempted to contact the accident flight; however, no response was recorded or noted. On August 4, 2013, about 1155 eastern daylight time, a Beech A36, N1831W, was destroyed when it impacted trees and terrain near Alma, Georgia. Day, visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The private pilot and passenger were fatally injured. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The flight departed Fernandina Beach Municipal Airport (FHB), Fernandina Beach, Florida around 1115 with the intended destination of Gwinnett County Airport-Briscoe Field (LZU), Lawrenceville, Georgia, where the airplane was based. A review of voice recordings provided by Jacksonville Air Traffic Control Tower (JAX) revealed no indication from the pilot of any anomalies. A radar hand-off was accomplished between JAX to Jacksonville Air Route Traffic Control Center (ZJX). The pilot contacted ZJK at 1127 and was issued the current altimeter setting. Then, at 1151, while en route at 5,000 feet mean sea level (msl), the airplane lost radar contact and the radar controller attempted to contact the pilot; however, no response was recorded or noted. A review of radar data indicated that the radar target began to descend from about 5,000 feet msl starting at 1150:52. The next radar targets were recorded at 4,900 feet msl at 1151:04, then 3,900 feet msl at 1151:16, and the last radar target was at2,800 feet msl at 1151:28. The wreckage was located about 2 miles to the northwest of the last radar return. Witnesses reported hearing a "low flying" airplane and soon after, the sound of impact. One witness went to the scene and notified the Sheriff's Department. The other witness stated that when he first heard the airplane it sounded like the engine was sputtering but it then straightened out. A postmortem examination of the pilot was performed by the Georgia Bureau of Investigation, Division of Forensic Sciences, on August 7, 2013. The autopsy report noted the cause of death as "multiple blunt force injuries" and the manner of death was "accident." Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated no ethanol was detected in the muscle or liver. Atorvastatin and Doxazosin were detected in the muscle and liver. Azacyclonol, Fexofenadine, and Ibuprofen were detected in the liver. In addition, testing for carbon monoxide and cyanide was not performed due to the lack of a suitable sample. No postmortem examination or toxicology tests were performed on the passenger. The 1153 recorded weather observation at AMG, which was about 8 nautical miles to the southeast of the accident location, included wind from 290 degrees at 5 knots, 8 miles visibility, scattered clouds at 3,200 feet above ground level (agl) and 4,600 feet agl, temperature 31 degrees C, dew point 23 degrees C, and barometric altimeter 30.04 inches of mercury. According to Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. He held a third-class medical certificate, which was issued on January 13, 2012 and had a restriction of "must wear corrective lenses." At the pilot's most recent medical examination he had reported 601 total flight hours and 40 of those flight hours were in the 6 months preceding the medical application. Engine Examination The engine was examined at the manufacturing facility in Mobile, Alabama, on September 10-11, 2013. The oil filter and fuel filter were void of any debris. The spark plugs were removed, all exhibited normal wear, and were light gray in color. The starter adaptor, induction system, exhaust system, oil cooler, manifold valve, throttle body, oil sump, oil suction screen, and cylinders were removed, disassembled, and examined with no anomalies noted. In addition, the camshaft and crankshaft were removed and examined. Overall, examination revealed that there were no abnormalities with the engine that would have precluded normal operation. The airplane impacted 60-foot-tall trees beyond an open field and then descended until it impacted the ground at a wings-level, nose down attitude. The accident flight path was oriented on a 304 degree heading and the debris path began at the initial tree strike and continued about 650 feetin length. Nose Section The engine was separated from the engine mounts and located about 50 feet forward of the main wreckage. The engine cowling was separated from the engine and located along the debris path. The nose gear was impact separated from the keel structure of the airplane and located in the vicinity of the main wreckage. The propeller and spinner remained attached to the propeller flange. The propeller blades exhibited S-bending. There were several pieces of smoothly-cut tree branches located along the debris path. The branches exhibited paint transfers along the faces of the cuts similar in color to the propeller blades. The cuts were about 45 degree angles to the plain of the branch. The engine remained attached to the firewall through wires but was separated from all of the engine mounts. All six cylinders remained attached to the crankcase. The No. 5 cylinder was impact damaged. Both magnetos were separated from the engine. The left magneto remained attached through the ignition harness and the right magneto was located along the debris field. The starter was separated from the engine and was located along the debris field. In addition, the alternator was impact fractured and several pieces were scattered throughout the debris field. Right Wing Sections of the right wing, right flap, and right aileron were scattered along the debris path. The inboard section of the right wing was located underneath the fuselage. The entire right wing exhibited impact crush damage. The flaps were impact separated at their respective attach points. Cable continuity was confirmed from the flap motor located near the cabin area to the actuators; however, they exhibited numerous tensile overload fractures. The aileron was separated from the wing and the aileron cables exhibited tensile overload at all fracture points; however, cable continuity was confirmed from the base of the control column to the associated fracture points out to the aileron. The right wing's main fuel tank fuel cap remained attached, was seated correctly, and locked in position in the forward right wing section located along the debris path. The right main landing gear was separated and discovered about 15 feet forward of the main wreckage. The right flap actuator was measured and corresponded to the flaps retracted position. Empennage The rudder remained attached to the vertical stabilizer. Cable continuity was confirmed from the base of the rudder pedals to the rudder through several cable fractures. All separations exhibited tensile overload signatures. All flight control surfaces associated with the tail section remained attached to their respective attach points; however, the empennage was separated from the fuselage. The left and right elevator counter weights were impact separated from the elevator and located along the debris path. Elevator cable continuity was confirmed from the base of the control column to the elevator bellcrank although numerous tensile overloadfractures were present along the entire span. Both elevator trims were measured and correlated to a nose down trim position. Left Wing The left wing was found inverted and separated from the fuselage at the wing root. The wing exhibited extensive crush and impact damage along the entire span. The fuel tanks were breached, devoid of fuel, and the fuel caps remained secured and seated. The flaps remained attached at their respective attach points at the flap bell crank. Flap control continuity was confirmed for the flaps although the drive cable was separated from the flap motor assembly in tensile overload. The aileron was separated and cable continuity was confirmed from the base of the control column to the associated fracture points out to the aileron attach point. The aileron cable exhibited tensile overload at all fracture points. The landing gear actuator was discovered in the retracted position. The left main landing gear remained in the up and locked position. The left flap actuator was measured and corresponded to the flaps retracted position. Cockpit The cockpit exhibited extensive impact and crush damage. A Garmin 696 handheld global positioning system was located, which was removed and sent to the NTSB Vehicle Recorder Laboratory for download. The engine controls were separated from the cockpit and located in the vicinity of the main wreckage. The throttle lever and the propeller lever were in the mid-range position. The mixture was in the full forward position. Due to extensive damage, the levers were impact separated from their associated control cables. The tachometer indicated a time of 2778.16 hours. The vertical speed indicator needle was in the 400 feet per minute down position. The aileron balance cable was intact from the left bellcrank to the right bellcrank where it exhibited overload failure at the right aileron. The transponder was examined and the setting of the transponder could not be determined. Fuselage The fuselage came to rest about 600 feet from the initial tree impact point. It came to rest on the left side. The main cabin door was separated from the fuselage. The main cabin door latch was in the closed position. In addition, both the forward and aft utility doors were in the latched and closed position; however, both were impact separated from the fuselage. The pilot and co-pilot seats were impact separated from the cabin and located forward of the main wreckage. The aft seats remained attached to the cabin floor. The fuel selector was located in the vicinity of the main wreckage. The fuel selector was located in the left main fuel tank detent. All of fuel fittings that attached to the fuel selector were finger tight. An odor similar to aviation fuel was noted when the fuel selector was disassembled. Residual liquid that was similar in odor to aviation fuel was noted in the fuel strainer with no debris noted in the fuel. Residual fuel was also noted in the fuel boost pump when it was disassembled. The fuel boostpump was in the "OFF" position. ## Aircraft - Registration: [N1831W](https://openairdocs.org/deregistered/N1831W-2018-03-12), registration cancelled 2018-03-12, S/N E-388, built 1973 (OpenAirDocs) - Reported make and model: BEECH A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-388 - Airframe hours: 2778 - Engines: CONT MOTOR IO-550-B 300 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Aps Aviation LLC - Registered owner: Aps Aviation LLC - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: Annual, July 8, 2013 - Departed: FHB, Fernandia Beach, FL - Destination: LZU, Lawrenceville, GA - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review March 30, 2013; seat: left; toxicology performed; flight hours: 657 total, 5 in the last 90 days, 5 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 290° at 5 knots - Visibility: 8 statute miles - Lowest ceiling: none - Temperature: 88 °F, dew point 73 °F - Altimeter: 30.04 inHg - Observed at: AMG, 8 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 20130804025769A](https://openairdocs.org/incident/20130804025769A), Aug 4, 2013: Beech A36, Alma, GA, Destroyed, 2 fatal. N1831W departed fernandina beach municipal airport (fhb), fernandina beach, Florida around 1115 on August 4, 2013, with the intended destination of gwinnett… ## Docket (18 files) The files NTSB released with the investigation on November 24, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=87660. 14.3 MB in all. - Witness Statements (item 1, .PDF, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398082&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - ATC Radar Data Graphic (item 2, .PDF, 686 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419356&FileExtension=.PDF&FileName=ATC%20Radar%20Data%20Graphic-Master.PDF - ATC Transcript (item 3, .PDF, 723 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409943&FileExtension=.PDF&FileName=ATC%20Transcript-Redacted.PDF - Air Traffic Controller Statements (item 4, .PDF, 393 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419357&FileExtension=.PDF&FileName=Air%20Traffic%20Controller%20Statements-Redacted.PDF - Most Recent Fuel Receipts (item 5, .PDF, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398083&FileExtension=.PDF&FileName=Most%20Recent%20Fuel%20Receipts-Redacted.PDF - Most Recent Maintenance Inspection (item 6, .PDF, 270 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405256&FileExtension=.PDF&FileName=Most%20Recent%20Maintenance%20Inspection-Redacted.PDF - Memorandum of Record - Alma, Georgia Weather (item 7, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398084&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20-%20Alma,%20Georgia%20Weather-Master.PDF - Memorandum of Record - Garmin 696 GPS Data (item 8, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419358&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20-%20Garmin%20696%20GPS%20Data-Master.PDF - Engine Examination Report (item 9, .PDF, 5.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419362&FileExtension=.PDF&FileName=Engine%20Examination%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 290 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40404658&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage (item 11, .PDF, 251 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419363&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage-Redacted.PDF - Toxicological Report (item 12, .PDF, 131 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40404660&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Revised Factual Report (item 13, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420264&FileExtension=.PDF&FileName=Revised%20Factual%20Report-Master.PDF - Photo 1 - Accident Site (item 14, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419364&FileExtension=.PDF&FileName=Photo%201%20-%20Accident%20Site-Master.PDF - Photo 2 - Engine (item 15, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419365&FileExtension=.PDF&FileName=Photo%202%20-%20Engine-Master.PDF - Photo 3 - Tachometer (item 16, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419366&FileExtension=.PDF&FileName=Photo%203%20-%20Tachometer-Master.PDF - Photo 4 - Descending Path through Trees (item 17, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419367&FileExtension=.PDF&FileName=Photo%204%20-%20Descending%20Path%20through%20Trees-Master.PDF - Photo 5 - Angularly cut wood at accident site (item 18, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419368&FileExtension=.PDF&FileName=Photo%205%20-%20Angularly%20cut%20wood%20at%20accident%20site-Master.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.