IAD98FA094

NTSB accident investigation · Beech A-36 · Amelia, OH · August 15, 1998

Accident · FatalField investigationFinal report
Date
August 15, 1998, 07:38 local (11:38 UTC)
Place
Amelia, OH
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N8EMBeech A-36
Weather
Instrument (IMC) · Day
Status
Completed · report March 31, 2000
Report
Approved by Office Director
FAA report
19980815020889A
Case key
43727

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 loss of control in flight due to spatial disorientation. A related factor was the fog.

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)
Weather condition - fogFactor
Became lost/disoriented - inadvertentPilot in command
Spatial disorientationPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The pilot departed on an IFR flight in instrument meteorological conditions without receiving a weather briefing. Weather reported in the area of the destination airport was ceiling 300 feet overcast with 1 mile visibility in fog. The instrument approach was flown 1 mile south of, and parallel to, the destination runway. The pilot performed a left turn during the missed approach procedure, followed by a right turn after he requested vectors for a return flight to the departure airport. Examination of radar data revealed that after the airplane completed the right turn and rolled out on the assigned heading, the airplane re-entered a right turn and descended in a right-hand spiral. Examination of the airframe and engine revealed no pre-impact anomalies. Photographs taken at the scene immediately following the accident showed reduced visibility due to fog.

Factual narrative

History of flight

On August 15, 1998, at 0738 eastern daylight time, a Beech A-36, N8EM, was destroyed when it collided with terrain in Amelia, Ohio, during a missed approach from the Clermont County Airport (I69), Batavia, Ohio. The certificated private pilot was fatally injured. Instrument meteorological conditions prevailed for the personal flight that originated at Hamilton, Ohio (HAO), at 0718, destined for I69. An instrument flight rules (IFR) flight plan was filed for the flight conducted under 14 CFR Part 91.

The purpose of the flight was to attend an American Bonanza Society (ABS) clinic at I69. In a telephone interview, the manager of the Clermont County Airport stated that ABS and Continental Teledyne provided thorough airplane inspections at very low cost. He said, "For 120 dollars, they get a 500 dollar inspection." The airport manager said the accident pilot had an appointment for 0730 at the clinic.

A review of Air Traffic Control (ATC) records revealed the pilot filed his IFR flight plan by telephone with the Dayton, Ohio, Flight Service Station (FSS), at 0707. There was no record that the pilot received a weather briefing prior to departure from HAO. The pilot received his IFR clearance over the aircraft's radio at 0718, from the Cincinnati Approach Control. The controller advised him that runway and weather information for the destination airport was unavailable.

A review of ATC voice communication tapes revealed the pilot requested the NDB runway 22 approach at I69. The pilot further requested the VOR approach if he was unable to complete the landing after the NDB approach.

After N8EM was established on the NDB 22 final approach course, ATC instructed the pilot to change to the UNICOM frequency at I69. At 0736, the pilot initiated the missed approach procedure and contacted Cincinnati Approach Control. The following excerpts were taken from the conversation between ATC and N8EM:

Pilot: "Eight echo mike missed approach at Clermont County."

Controller: "Bonanza eight echo mike radar contact. Turn left heading one five zero. Climb and maintain two thousand five hundred. We'll vector you for the VOR bravo."

Pilot: "Bonanza eight echo mike. Maybe I'll go back to Hamilton. It doesn't look...It's lower than that over here."

Controller: "Eight echo mike, okay. Turn right heading 360 for Hamilton. Climb and maintain three thousand, eight echo mike."

Pilot: "Three thousand and bonanza eight echo mike. And what was the heading?"

Controller: "Three six zero heading, right turn."

Pilot: "Zero...Three six zero."

The pilot then requested the localizer approach at Hamilton Airport. Radar contact was lost, at 0738. The airplane collided with terrain approximately 1.5 miles south of I69 on a magnetic heading of approximately 290 degrees.

A witness who held a private pilot's certificate and approximately 900 hours of flight experience stated he was about 1 mile south of the airport when he heard the airplane overhead. He said:

"I could hear him come around and, honest to God, it sounded like he was right on top of the trees. That thing was running beautiful, I mean it purred. I was looking for him, but I couldn't find him. The fog this morning, you couldn't see from here to that house. He was on treetop level, right above my head and I couldn't see him. Seriously, I was looking because he was so damn low. There was no engine trouble, he was running good."

In a statement provided to the Ohio State Police, a second witness stated he was standing approximately 300 yards from the crash site when he heard the airplane. He reported that he could not see the airplane due to thick fog. The witness stated:

"The plane sounded normal, the motor sounded smooth and normal, no sputtering or missing. The motor was running all the way until the plane crashed...The engine never quit. It stayed running until it hit the ground."

The accident occurred during the hours of daylight approximately 39 degrees, 03 minutes north latitude, and 84 degrees, 12 minutes west longitude.

Personnel information

The pilot held a private pilot certificate with ratings for airplane single engine land and instrument airplane. His most recent Federal Aviation Administration (FAA) Third Class Medical Certificate was issued on October 7, 1996.

The pilot's logbook revealed 621.5 hours of total time logged. The pilot had accumulated approximately 100 hours of actual instrument and 82 hours of simulated instrument time. The pilot's last instrument competency check was completed September 14, 1997.

Aircraft information

The airplane was a 1979 Beech A36. The airframe had accumulated 2,638 hours of total time. The last annual inspection was performed February 12, 1998 and the airplane accrued 54 hours of flight time since that date.

Meteorological information

Weather reported at HAO at the time of departure was: visibility 3/4 mile in fog and no wind.

Weather reported at the Cincinnati Municipal Airport/Lunken Field, 10 miles northwest of I69, at 0730 was: ceiling 300 overcast with 1 mile visibility in fog and no wind.

Photographs taken at the scene immediately following the accident by local police showed reduced visibility due to fog.

Wreckage and impact information

The wreckage was examined at the site on August 15, 1998. There was a strong odor of fuel and all major components were accounted for at the scene. The distance from the initial ground scar to the main wreckage was approximately 130 feet. The wreckage path was divided into one foot increments identified as wreckage points (WP). The propeller was buried in a crater approximately 3 feet deep, 30 feet beyond the initial ground scar. All three propeller blades displayed similar twisting, bending, leading edge gouging, and chordwise scratching.

The engine was separated from the airframe and came to rest inverted at WP 69. The fuel lines between the flow divider manifold and the cylinders contained fuel.

The main wreckage came to rest inverted, facing opposite the direction of travel. The cockpit and cabin areas were completely destroyed by impact. The roof was separated from the airplane and lay perpendicular to the wreckage path and the fuselage. The right wing was separated from the airplane and disintegrated along the wreckage path. Control cable continuity was established from the cockpit area to all flight control surfaces except the right wing. Cable continuity was established from the cockpit area to the point of right wing separation where the cables appeared to have failed in overload.

Medical and pathological information

Dr. Gary L. Utz performed an autopsy on the pilot on August 15, 1998 for the Clermont County Coroner's Office.

The FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma performed toxicological testing.

Tests and research

The engine was examined at the Lunken Airport, Cincinnati, Ohio, on August 17, 1998. The engine was rotated by hand and continuity was established through the powertrain to the accessory section. Compression was verified on five of six cylinders using the thumb method. The valves on the #5 cylinder would not fully close due to impact damage. Both magnetos were partially separated due to impact damage. The magnetos were removed and placed on a test stand. Both magnetos produced spark at all terminal leads.

The final approach course for the NDB Runway 22 approach at Clermont County Airport was the 229-degree bearing to the SPORTYS non-directional beacon. It was a terminal approach with the missed approach point at station passage at the beacon. The minimum descent altitude for aircraft equipped with dual ADF receivers was 1,340 feet. Dual ADF weather planning minimums for the straight-in Runway 22 approach were: ceiling 500 feet with 1 mile visibility.

Weather reported at the Cincinnati Municipal Airport/Lunken

Aircraft

Registration
N8EM
Reported as
Beech A-36
Category
Airplane
Serial number
E1439
Airframe hours
2,638
Engine
Continental IO-520-BA, 285 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
John K. Krieg
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · February 12, 1998 · 54 hours before
Departed
HAO · Hamilton, OH
Destination
I69 · Batavia, OH
Flight plan
IFR
Airport
I69 · Clermont County Airport, runway 22, 3,705 × 75 ft, asphalt

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
57
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
621 total · 90 in this make and model · 20 in the last 90 days · 10 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
Calm
Visibility
1 statute miles
Lowest ceiling
100 ft overcast
Temperature
68 °F, dew point 68 °F
Altimeter
29.00 inHg
Observed at
LUK, 10 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.

Other investigations on N8EM · 1

Matched to the same aircraft by N-number and date.