LAX01FA001

NTSB accident investigation · Beech A36TC · San Juan Batist, CA · October 2, 2000

Accident · FatalField investigationFinal report
Date
October 1, 2000, 20:10 local (Oct 2, 2000, 03:10 UTC)
Place
San Juan Batist, CA
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N36TVBeech A36TC
Weather
Instrument (IMC) · Night/dark
Status
Completed · report June 2, 2004
Report
Approved by Office Director
Parties
Raytheon Beech, Teledyne Continental Motors, Federal Aviation Administration
FAA report
20001001040299A
Case key
50390

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 in-flight decision to continue flight into instrument weather conditions at an altitude that did not maintain an adequate terrain clearance, which resulted in a collision with terrain. Factors were a dark night, clouds, fog, mountainous terrain, and lack of instrument rating.

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 weatherDescent
Light condition - dark nightFactor
Weather condition - cloudsFactor
Weather condition - fogFactor
In-flight planning/decision - inadequatePilot in commandCause
Vfr flight into imc - inadvertentPilot in commandCause
Altitude/clearance - not maintainedPilot in commandCause
Lack of certificationPilot in commandFactor
In flight collision with terrain/waterDescent
Terrain condition - mountainous/hilly

Analysis

The airplane collided with mountainous/hilly terrain as the pilot descended in instrument conditions toward the destination airport. The non-instrument rated pilot was obtaining VFR flight advisories from Air Traffic Control, and told approach control that he intended to head for his destination in visual conditions. A few minutes later the pilot stated that he intended to circle down through a hole. At this time, approach lost radar contact at a mode C reported altitude of 3,500 feet on a southeasterly track in an area of hilly terrain where it is not uncommon to loose radar contact at that altitude or less. The controller assumed that he was losing the radar contact, terminated radar service, and approved a frequency change. The controller did not hear a response from the airplane. At 2009:29, the target was at a mode C reported altitude of 2,200 feet. By 2011:03, the target had turned left on a southwesterly track and was at a mode C reported altitude of 1,300 feet. This was the last recorded target for the flight's assigned secondary beacon code. The accident site elevation was about 1,000 feet. A resident who lived near the accident site reported that it was very foggy about the time of the accident, and estimated that the visibility was 100 feet..

Factual narrative

History of flight

On October 1, 2000, about 2010 Pacific daylight time, a Beech A36TC, N36TV, collided with mountainous/hilly terrain near San Juan Bautista, California. The pilot/owner was operating airplane under the provisions of 14 CFR Part 91. The private pilot and three passengers sustained fatal injuries. The airplane was destroyed. The personal cross-country flight departed Mammoth Lakes, California, about 1845, en route to Watsonville, California. Visual meteorological conditions prevailed at Salinas, California, the nearest reporting station, which was 11 miles from the accident site. Witnesses in the area of the accident site reported that instrument meteorological conditions consisting of coastal low clouds and fog prevailed at the accident site. No flight plan had been filed. The primary wreckage was at 36 degrees 49.702 minutes north latitude and 121 degrees 34.59 minutes west longitude.

The pilot and three friends flew from Watsonville to Mammoth Lakes in the morning with the return trip scheduled for that afternoon. About 1730, one of the passengers called a family member to inform them that the return would be delayed. The passenger said that the flight should be about 1 1/2 hours long, and they would not arrive until 2130.

The Federal Aviation Administration (FAA) submitted a summary of recorded radio transmissions between air traffic control facilities and N36TV. The pilot checked in with Oakland Air Route Traffic Control Center when he was 20 miles west of Mammoth Lakes at 14,000 feet and requested flight following. Oakland identified the airplane and provided a discreet secondary beacon code of 3354. Eventually, control passed to Monterrey Approach Control (SECA).

At 2002:53, the pilot reported that he was leaving 8,000 feet for 4,500 feet. He stated that his intensions were to head for Watsonville in visual conditions.

The National Transportation Safety Board investigator-in-charge (IIC) reviewed recorded radar data. A target with the secondary beacon code of 3354 maintained a southwesterly descent. At 2004:32, the target was at a mode C reported altitude of 7,400 feet and began a turn to the southeast. It maintained the southeasterly track and continued to descend.

At 2005:11, the pilot stated that he intended to circle down through a hole. He requested that SECA provide him the frequency for the Watsonville ASOS (Automated Surface Observation System). The transmission was not clear, and it took several attempts for the controller to understand and comply with the request. The pilot acknowledged the frequency at 2008:03, and the transcript indicated that there was no other contact with the airplane. At this time, the radar contact was at a mode C reported altitude of 3,500 feet, and maintaining a southeasterly track.

At 2008:58, the Monterey local controller contacted SECA to assume the approach control duties. SECA stated that N36TV was the only airplane that the local controller would be talking to, and it was maneuvering north of Salinas en route to Watsonville. The local controller mentioned that at first he thought the airplane was going southeast, but now it was going northeast.

As the two controllers discussed N36TV, SECA pointed out that the airplane had been at 6,500 feet. SECA mentioned that the local controller would lose the radar target as the airplane descended and might consider terminating radar services. At 2009:52, the controllers noticed that the target went into coast mode. The local controller broadcast to N36TV that he was losing the radar contact. The local controller terminated radar service and approved a frequency change. The controller did not hear a response from the airplane.

At 2009:29, the target was at a mode C reported altitude of 2,200 feet. By 2011:03, the target had turned left on a southwesterly track, and was at a mode C reported altitude of 1,300 feet. This was the last recorded target for secondary beacon code 3354.

The main wreckage was at an estimated elevation of 1,000 feet.

Personnel information

A review of FAA airman records revealed the pilot held a private pilot certificate with an airplane single-engine land rating. The pilot held a third class medical certificate that was issued on April 13, 1999. It had the limitations that the pilot must wear lenses for distant vision and possess glasses for near vision. The pilot's logbook was not recovered.

A review of FAA records revealed that the pilot did not possess an instrument rating.

Aircraft information

The airplane was a Beech A36TC, serial number EA-33. The airplane's logbooks were not recovered. A work order from a maintenance facility revealed a total airframe time of 3,524 hours at the last annual inspection. The work order indicated that the maintenance facility completed an annual inspection on July 14, 2000. Another work order for an oil change dated August 11, 2000, indicated a tachometer time of 3,541 hours.

The airplane's engine was a Teledyne Continental Motors TSIO-520-UB, serial number 809371-R. A maintenance facility installed a factory-rebuilt engine at the annual inspection.

Fueling records at Hot Creek Aviation, Mammoth Lakes, established that the airplane was last fueled at 1746 on October 1, with the addition of 21.8 gallons of 100-octane aviation fuel.

Meteorological information

Residents who lived within 1 mile of the accident site reported that it was very foggy about the time of the accident. One resident estimated that the visibility was 100 feet. He said the fog persisted into the next morning and everything was soggy.

The closest official weather observation station was Salinas (SNS). The elevation of the weather observation station was 84 feet msl. An aviation routine weather report (METAR) issued at 1953 reported: skies overcast at 500 feet; fog; visibility 5 miles; winds 320 degrees at 8 knots; temperature 61 degrees Fahrenheit; dew point 59 degrees Fahrenheit; and altimeter 29.92 inHg.

A METAR issued at 1953 for Watsonville, the destination airport, reported: skies overcast at 200 feet; fog; visibility 3 miles; winds 270 degrees at 4 knots; temperature 59 degrees Fahrenheit; dew point 59 degrees Fahrenheit; and altimeter 29.93 inHg.

Safety Board software determined that Watsonville was 12 miles from the accident site on a magnetic bearing of 285 degrees. Salinas was 11 miles from the accident site on a magnetic bearing of 171 degrees.

Safety Board software determined that sunset occurred at 1851, and there was 19 percent illumination of the moon.

Communications

The airplane was in contact with Monterey Approach Control on frequency 133.00, with no communications difficulties reported by ATC.

Wreckage and impact information

The accident site was in rolling hills with scattered clusters of trees. The main wreckage was on a 45-degree upslope. The debris path began midway up a ridgeline, and continued up hill. The debris path was along a magnetic bearing of 300 degrees, and the upslope shallowed to 5 degrees within 10 feet of the main wreckage. The fuselage came to rest on a heading of 250 degrees. The empennage was along a heading of 210 degrees.

An inverted U-shaped burn area began at the main wreckage. An area of burned grasses and bushes extended about 60 feet forward of the main wreckage. It fanned out about 60 feet to the left and 30 feet to the right of the debris path centerline. A 10-foot-wide burn area at the most forward part of the burn area continued 90 degrees to the right and widened to 25 feet. After about 80 feet, it turned 90 degrees to the right, and fanned out as it went back downslope about 60 feet.

The engine separated and was a few feet in front of the main wreckage. The exhaust tubes were crushed and buckled, but not cracked.

The propeller blades separated and were several feet forward of the hub. The central shaft of the propeller and the

Aircraft

Registration
N36TV
Reported as
Beech A36TC
Category
Airplane
Serial number
EA-33
Airframe hours
3,524
Engine
Teledyne Continental TSIO-520-UB, 300 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Serge J. Herring
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · July 14, 2000
Departed
MMH · Mammoth Lakes, CA
Destination
WVI · Watsonville, CA

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
51
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
320° at 8 knots
Visibility
5 statute miles
Lowest ceiling
500 ft overcast
Temperature
61 °F, dew point 59 °F
Altimeter
29.00 inHg
Observed at
SNS, 11 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.