FTW02FA087

NTSB accident investigation · Beech A36 · Austin, TX · March 1, 2002

Accident · FatalField investigationFinal report
Date
March 1, 2002, 16:41 local (22:41 UTC)
Place
Austin, TX
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N7236LBeech A36
Weather
Instrument (IMC) · Night/dark
Status
Completed · report July 23, 2003
Report
Approved by Office Director
Parties
Federal Aviation Administartion, Federal Aviation Administration, Raytheon Aircraft Company, Teledyne Continental Motors
FAA report
20020301001809A
Case key
54286

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 airspeed, resulting in a stall. Contributing factors were the low ceiling, fog, and the unforecast weather conditions..

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.

Loss of control - in flightMissed approach (ifr)
Airspeed - not maintainedPilot in commandCause
Stall - inadvertentPilot in commandCause
Weather condition - low ceilingFactor
Use of inappropriate medication/drugPilot in command
Weather condition - fogFactor
Weather forecast - inaccurateFactor
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The instrument-rated private pilot received a preflight weather briefing from a flight service station, and was informed of light turbulence and a forecast of marginal VFR conditions becoming VFR at the destination airport near the estimated time of arrival. The flight departed and flew to the destination airport. Prior to beginning an ILS approach, the pilot was informed of IFR weather conditions, which consisted of a ceiling and visibility below the minimum prescribed altitudes for the approach. The pilot executed a stable ILS approach to the runway and, according to radar data, declared a missed approach at the decision height. The pilot was issued missed approach instructions at three separate times, and acknowledged the first two sets of instructions; however, did not respond to the final instruction to switch communication frequencies. Subsequently, the airplane was located on the airport property. Witness marks at the accident site and airplane crush angles were consistent with the airplane stalling prior to impacting the ground, and then a fire erupting. Examination of the airframe and engine, and their logbooks, did not reveal any pre-existing anomalies. Additionally, toxicological test results for the pilot revealed unquantified levels of dyphenhydramine (a sedating antihistamine).

Factual narrative

History of flight

On March 1, 2002, at 1641 central standard time, a Beech A36 single-engine airplane, N7236L, was destroyed when it impacted terrain during a missed approach at the Austin Bergstrom International Airport (AUS), near Austin, Texas. The airplane was registered to and operated by the pilot. The instrument rated private pilot and his non-pilot rated passenger received fatal injuries. The flight was in instrument meteorological conditions at the time of the accident, and an instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations Part 91 personal flight. The 320-nautical mile cross-country flight originated from the Wiley Post Airport (PWA), Oklahoma City, Oklahoma, at 1358, and was destined for Austin.

At 0959, the pilot contacted the Mc Alester Automated Flight Service Station (MLC AFSS) and requested a weather briefing for an IFR flight from PWA to AUS departing at 1400 cst. The briefer informed the pilot of an Airmet for light turbulence along the route of flight. The briefer also informed the pilot of the terminal forecast for AUS, which included: Before 1600, clouds scattered and broken at 400 and 1,500 feet, respectively. After 1600, clouds scattered at 3,000 feet, ceiling 6,000 feet broken, and visibilities greater than 6 miles. At 1358, the airplane departed PWA and flew to Austin.

According to FAA air traffic control (ATC) records, at 1616, the flight was at 6,000 feet and contacted Austin Terminal Radar Approach Control Facility (AUS TRACON). At 1617, the flight was issued the weather for AUS (wind from 020 at 4 knots, visibility 1/4 miles in fog, runway 17L runway visual range (rvr) 1,800 feet at touchdown, 2,000 feet at mid-field and 2,000 at feet roll-out, and ceiling 100 foot overcast) and was told to expect the instrument landing system (ILS) approach to runway 17L.

At 1629, the flight was cleared for the ILS approach to runway 17L. At 1633, the flight was cleared to land on runway 17L. At 1637, the pilot declared a missed approach and the tower controller issued the following instructions: Fly runway heading and maintain 3,000 feet. The pilot acknowledged. At 1638, the tower controller issued the following instructions: As soon as speed and altitude permit turn left heading 080 degrees and maintain 3,000 feet. The pilot acknowledged the instructions. At 1638:49, the flight was instructed to contact approach on 125.32, and the pilot acknowledged. The flight did not check in on 125.32, and no distress calls were received.

Radar data from the approach phase of flight revealed, the airplane was in a steady descent and only small heading changes were made during the approach. The airplane descended to an altitude of 700 feet msl (209 feet agl) and then a climb was initiated to 400 feet. At 1638:50, the final radar return was received, and the final radar return depicted the airplane at 900 feet msl (500 feet agl).

At 1642, the Austin Air Traffic Control Tower (AUS ATCT) notified the Airport Fire Department, Police Department, and airport personnel of a possible airplane accident and a search was initiated. At 1740, airport personnel located the airplane approximately 1/4 mile east of the departure end of runway 17L (east of the runway 35R localizer centerline in the southeast corner of the airport). The airplane was found engulfed in flames. Airport Rescue Fire Fighters (ARFF) responded and a pathway was cleared through heavy brush and trees into the accident site. At 1845, ARFF accessed the accident site, and at 1850, the fire was extinguished.

Personnel information

The pilot was issued a private pilot certificate on April 18, 1987. He held single and multi-engine land ratings and an instrument rating. On July 9, 2001, he completed his most recent biennial flight review (BFR). According to the check pilot who administered the BFR, the accident pilot completed appropriate maneuvers for an airplane check-out and the BFR. He stated that some basic instrument flying was accomplished and approximately three instrument approaches were flown. The check pilot does not recall the pilot being deficient in any areas. According to insurance company records, as of July 2001 the pilot had accumulated a total of 682 hours, of which 210 were in the make and model of the accident airplane, and 604 were in retractable gear airplanes. The pilot's logbook was not located during the investigation.

He held a third class medical certificate that was issued on June 1, 2001.

Aircraft information

The 1985 model airplane was equipped with a 300-horsepower Teledyne Continental IO-550-B engine (serial number 296620R) and a 3-bladed, constant speed McCauley propeller. The airplane was also equipped with a KFC-150 flight director (autopilot).

On April 22, 2000, the airplane underwent its most recent pitot-static inspection. On May 22, 2001, the airframe and engine underwent their most recent annual inspections, at which time they had accumulated a total of 2,082.8 hours and 522.2 hours since major overhaul, respectively. A review of the airframe, engine and propeller logbooks did not reveal any uncorrected maintenance entries.

Aerodrome information

Austin Bergstrom International Airport's runway 17L is 9,000 feet long and 150 feet wide. The runway is equipped with high intensity runway lights (HIRL), a standard 2,400 foot high intensity approach lighting system with centerline sequenced flashers (ALSF-II), and an Precision Approach Path Indicator (PAPI-L). Runway 17L is also equipped with an ILS approach and landing system. The decision height for the ILS runway 17L approach is 691 feet msl, (200 feet agl) and the minimum landing visibility is 0.5 miles or a runway visual range of 1,800 feet.

On March 5, 2003, a flight inspection, conducted by the FAA, of the instrument landing system revealed no anomalies with any part of the system, including the localizer, glide slope, distance measuring equipment, and lighting system.

Meteorological information

At 1619, the weather observation facility at AUS issued a special meteorological aerodrome report (METAR) with the following weather conditions: wind from 020 degrees at 3 knots, visibility 1/4 statute mile, runway 17L visual range 1,800 feet variable 2,000 feet, fog, ceiling 100 feet overcast, temperature 14 degrees Celsius, dew point 14 degrees Celsius, and an altimeter setting of 29.97 inches of Mercury.

At 1653, the weather observation facility at AUS reported the following weather conditions: overcast ceiling at 100 feet, visibility 1/4 statute miles in light rain and fog, temperature 14 degrees Celsius, dew point 14 degrees Celsius, runway visual range 2,000 feet variable to 2,400 feet, and an altimeter setting of 29.91 inches of Mercury.

According to emergency response personnel, the ground visibility was limited to approximately 15-20 feet due to heavy fog.

Wreckage and impact data

The main wreckage was located 2,410 feet east of the departure end of runway 17L. A Global Positioning System (GPS) recorded the accident location at north 030 degrees 10.810 minutes latitude and west 097 degrees 39.011 minutes longitude, at an elevation of 462 feet msl. The airplane came to rest intact in a wooded area on a measured magnetic heading of 190 degrees. The only trees with freshly severed limbs were located directly above the main wreckage. The cockpit and cabin were consumed by a fire. Both wings sustained fire damage from their roots outboard to midspan. Both wing leading edges were crushed aft to the front wing spars (from wing-tip to wing-tip). The left main landing gear assembly was displaced upward through the left wing's upper wing skin. The tail section was intact; however, sustained fire damage. The landing gear was found extended, and the flaps were found extended 15 degrees (approach setting). Flight control continuity was establishe

Aircraft

Registration
N7236L
Reported as
Beech A36
Category
Airplane
Serial number
E-2268
Airframe hours
2,082.8
Engine
Continental IO-550-B, 300 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Morris S. Curry
Airworthiness certificate
Standard, Utility
Last inspection
Annual · May 22, 2001
Departed
PWA · Oklahoma City, OK
Destination
AUS · Austin, TX
Flight plan
IFR
Airport
AUS · Austin Bergstrom Intl, runway 17L, 9,000 × 150 ft, concrete

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
63
Injuries
Fatal
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Last flight review
July 9, 2001
Seat
Left
Toxicology
Performed
Flight hours
682 total · 210 in this make and model

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
Calm
Visibility
0.25 statute miles
Lowest ceiling
100 ft overcast
Temperature
57 °F, dew point 57 °F
Altimeter
29.70 inHg
Observed at
AUS

Docket · 36

The files NTSB released with the investigation on May 27, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 11.7 MB in all.

Statements from Emergency RespondersItem 1 · .PDF · 687 KBReports from Parties to the Investigation (Teledyne Continental Motors)Item 2 · .PDF · 62 KBReports from Local Agencies (Austin Fire Department)Item 3 · .PDF · 296 KBReports from Local Agencies (Austin Police Department)Item 4 · .PDF · 561 KBAir Traffic Control DataItem 5 · .PDF · 1.2 MBRadar DataItem 6 · .PDF · 424 KBAerodrome DataItem 7 · .PDF · 102 KBDiagrams, MapsItem 8 · .PDF · 65 KBWeather, Sun and Moon DataItem 9 · .PDF · 129 KBPilot RecordsItem 10 · .PDF · 111 KBMaintenance RecordsItem 11 · .PDF · 1.1 MBFlight Inspection Report (ILS)Item 12 · .PDF · 229 KBData on DipenhydramineItem 13 · .PDF · 847 KBStatement of Party Representatives to NTSB InvestigationItem 14 · .PDF · 346 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 15 · .PDF · 106 KBToxicological ReportItem 16 · .PDF · 122 KBPhoto 1: Aerial view #1. Green arrow points to the accident site. (Courtesy Austin PD, No Neg)Item 17 · .PDF · 322 KBPhoto 2: Aerial View #2. Green arrow points to the accident site. (Courtesy Austin PD, No Neg)Item 18 · .PDF · 341 KBPhoto 3: Aerial view of the accident site. (Courtesy Austin PD, No Neg)Item 19 · .PDF · 532 KBPhoto 5: View of the accident site.Item 20 · .PDF · 282 KBPhoto 6: Another view of the accident site.Item 21 · .PDF · 292 KBPhoto 7: Close-up view of the burned cockpit/cabin area.Item 22 · .PDF · 288 KBPhoto 8: View of the crush angles on the wing's leading edge. Note leading adge compressed aft to main spar.Item 23 · .PDF · 212 KBPhoto 9: Another view of the burned fuselage.Item 24 · .PDF · 270 KBPhoto 10: View of the landing gear, which was displaced through the uipper skin surface of the wing.Item 25 · .PDF · 224 KBPhoto 11: View of the engine being extricated from the ground.Item 26 · .PDF · 274 KBPhoto 12: Close-up view of the engine.Item 27 · .PDF · 303 KBPhoto 13: View of the propeller blades.Item 28 · .PDF · 304 KBPhoto 14: Main fuel screen. Note clear. (Courtesy TCM, No Neg)Item 29 · .PDF · 246 KBPhoto 15: Oil filter element. Note no metal particles present. (Courtesy TCM, No Neg)Item 30 · .PDF · 308 KBPhoto 16: Top spark plugs. (Courtesy TCM, No Neg)Item 31 · .PDF · 173 KBPhoto 17: Vacuum pump prior to disassembly. (Courtesy TCM, No Neg)Item 32 · .PDF · 225 KBPhoto 18: View of the vacuum pump. (Courtesy TCM, No Neg)Item 33 · .PDF · 192 KBPhoto 19: Vacuum pump vanes.Item 34 · .PDF · 157 KBPhoto 20: View of the vacuum pump rotor.Item 35 · .PDF · 163 KBPhoto 21: View of the directional gyro (gimbal and housing). (Courtesy TCM, No Neg)Item 36 · .PDF · 171 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.