# NTSB LAX94LA045: Beech A-36, N9MP, Florence, AZ, November 15, 1993 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: November 14, 1993, 19:50 local (Nov 15, 1993, 02:50 UTC) - Place: Florence, AZ - Location: 33.0315° N, 111.3873° W: Placed by OpenAirDocs: center of Florence, AZ, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=33.0315&lon=-111.3873&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 2 serious, 1 minor, 6 uninjured - Status: Completed, report September 13, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 28599 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX94LA045 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28599/pdf - Page: https://openairdocs.org/ntsb/LAX94LA045 ## Probable cause the pilot's poor inflight planning and decision making by continuing the flight into adverse weather conditions. Factors contributing to this accident were: not obtaining a preflight weather briefing, not following the airplane flight manuals, and exceeding the weight and balance limits of the airplane. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - weather condition - icing conditions (contributing factor) - preflight briefing service - not obtained, pilot in command (contributing factor) - in-flight planning/decision - poor, pilot in command (cause) - flight into known adverse weather - attempted, pilot in command (cause) - Loss of engine power(total) - nonmechanical, descent - flight manuals - not followed, pilot in command (contributing factor) - aircraft weight and balance - exceeded, pilot in command (contributing factor) - lack of recent instrument time, pilot in command - In flight collision with terrain/water, descent - emergency - terrain condition - rough/uneven ## Analysis The pilot did not receive a weather briefing prior to departing. An airman's meteorological information advisory (AIRMET) was issued for the pilot's route of flight. The AIRMET forecasted occasional moderate mixed icing along the flight between 6,000 feet msl and 17,000 feet msl. The pilot requested and received an IFR clearance to Tucson, Arizona, at an altitude of 11,000 feet. The pilot reported that the airplane was picking up ice, and he was unable to maintain altitude. The pilot later reported that the engine had quit, and rudder control was lost. The manufacturer's pilot operating manual specifically prohibits 'flight into icing conditions.' Postaccident data determined the airplane was almost 500 pounds over gross weight at takeoff with the center of gravity 2.0 inches aft of the limit. Examination of the pilot's logbooks revealed that he was not instrument current under FAR 61.57 (e). Postaccident tests revealed that the engine ran at full operating RPM during tests at the engine manufacturer. ## Factual narrative HISTORY OF FLIGHT On November 14, 1993, at 1950 hours mountain standard time, a Beech A-36, N9MP, collided with desert terrain near Florence, Arizona, after a reported loss of power. The pilot was conducting an instrument flight rules (IFR) personal flight to Tucson, Arizona. The airplane, operated by Wasatch New Horizons, Inc., Heber City, Utah, sustained substantial damage. The certificated private pilot and the right front seat passenger received serious injuries; one passenger sustained minor injuries, and six passengers were not injured. The flight originated at Heber City, Utah, at an undetermined time. Night instrument meteorological conditions prevailed at the time. There was no record that the pilot received an aviation briefing from the Cedar City Flight Service Station, Cedar City, Utah, prior to departure. An airman's meteorological information advisory (AIRMET) was issued for the pilot's route of flight. The AIRMET forecasted occasional moderate mixed icing during the flight between 6,000 feet mean sea level (msl) and 18,000 feet msl. At 1956 hours, the pilot contacted Prescott Automated Flight Service Station (hereby referred to as AFSS), and requested the current Phoenix and Tucson weather. The briefer at the flight service station asked the pilot if he "had the flight precautions going that way." The pilot replied, "negative." Prescott AFSS reported the following in part, "low ceilings and visibilities are predicted from ah Prescott to just north of Phoenix all the way to Tucson...icing is forecast moderate mixed icing from seven thousand up to flight level one eight zero and turbulence is possible at any altitude below sh moderate turbulence below any altitude at thirty eight thousand feet and the mountains are forecast to be locally obscured over most of the state of Arizona..." At 1857 hours, the pilot told Prescott AFSS that, "I'd like to ah pick up an IFR (instrument flight rules) flight plan ah, into ah, probably Phoenix ah, I just got up into the clouds about ten and I'm picking up a little bit of ice." During the next minute, there were several attempts by the pilot to contact Prescott AFSS to file an IFR flight plan. The pilot made several inquiries to Prescott AFSS about conditions in various locations throughout the state of Arizona. At 1859 hours, the pilot told Prescott AFSS, "Ok, ah nine mike papa ah, ah, Tucson doesn't look very good." Prescott AFSS told the pilot, "November niner mike papa, VFR (visual flight rules) is not recommended ah across this state at all because of a flight precaution for low for solid overcast ceilings and mountain obscuration..." During the next three minutes, Prescott AFSS made several attempts to contact the pilot of the accident airplane to gather the information necessary to file the IFR flight plan. According to the transcript of the conversation between the pilot and Prescott AFSS, there were several broken up transmissions and squeals on the radio which rendered communication difficult. At 1906 hours, Prescott AFSS told the pilot to "contact Albuquerque Center on frequency 135.72." At 1933 hours, the pilot contacted Albuquerque Air Route Traffic Control Center (ARTCC), about 67 miles northwest of Tucson, Arizona, and stated, "a yes I'd like to pick up an IFR clearance into Tucson...I'm about ah I show sixty seven ah DME (distance measuring equipment) out of Tucson." The sector controller issued the pilot an IFR clearance and instructed the pilot "squawk two six one four." At 1935 hours, the sector controller said, "Bonanza niner mike papa radar contact six four miles north of Tucson VORTAC cleared to Tucson via direct climb and maintain one two thousand, Tucson altimeter two niner eight four." The pilot repeated the clearance he was given. At 1940 hours, while climbing, the pilot reported to ARTCC that the airplane was "picking up a little uh ice uh, and requested to stay at eleven thousand (feet mean sea level)." The sector controller cleared the pilot to 11,000 feet msl. At 1942 hours, the pilot requested, "is there any way you can give me any lower, I'm pickin up quite a bit of ice..." The sector controller cleared the pilot to maintain block seven thousand through one one thousand. At 1945 hours, the pilot then reported he was "having engine trouble...I'm freezing up." At 1947 hours, the sector controller asked the pilot if he was able to "maintain altitude now." The pilot of the accident airplane responded "nine pike papa uh negative." The sector controller informed the pilot of the location of the Coolidge Municipal Airport and asked the pilot to let him know if he needed to divert. At 1947 hours, the pilot informed the controller that "uh nine mike papa ...uh I just lost everything uh all my controls uh I'm I'm in trouble here." The controller gave the pilot radar vectors to the Coolidge Municipal Airport. The pilot responded at 1948 hours, "ok nine mike papa two seven zero, uh uh I I've really lost her here though." The last communication that the sector controller received from the pilot was that "I've lost all rudder control...the engine is not operating," which was transmitted at 1949 hours. The sector controller received a transmission from Southwest Airlines Flight 1595, "yes sir, we were monitoring that uh with that bonanza and uh we're now picking up an ELT on uh twenty one five." A crew from the Arizona Department of Public Safety (DPS), Southern Air Rescue, Tucson, Arizona, was notified at 2015 hours by their DPS dispatch of "an aircraft going down." The pilot of the mission reported that he checked weather in the area prior to departing on the rescue mission. He reported that the "weather in Tucson and Arizona had been worsening all day." He reported that the Tucson Flight Service Station told him in part, "moderate icing above 6,000 feet mean sea level, moderate turbulence, mountain obscuration in clouds and fog." The DPS rescue unit departed Tucson at 2035 hours, and attempted to reach the accident site. They were forced to abort their mission three times due to "limited visibility and heavy rain." The DPS rescue unit flew to the Florence,Arizona, hospital to wait for better weather. Meanwhile, they directed ground crews to the location of the crash site. CREW INFORMATION The pilot's logbook detailing his aeronautical experience was recovered from the pilot's wife. The last entry made in the logbook was on November 2, 1993. As of that date, the pilot had logged a total of 3,032 flight hours. Logbook entries made by the pilot showed a total of 65.3 hours of simulated instrument experience and 8.0 hours of actual instrument experience. According to the Federal Aviation Administration (FAA) inspector who reviewed the logbooks, the pilot was not instrument current in accordance with current Federal Aviation Regulation 61.57(e). According to the FAA Airman Certification Branch, the pilot was issued his instrument rating on April 23, 1992. AIRCRAFT INFORMATION The airplane's airframe and engine logbooks were recovered from the pilot's wife. An examination of the logbooks did not reveal any unresolved discrepancies prior to departure the day of the accident. According to the airplane manufacturer, under the "Limitations" section of the Beechcraft Bonanza A36TC Pilot Operating Manual, "flight in icing conditions prohibited." (See section 8.5 for additional information.) METEOROLOGICAL INFORMATION The nearest weather reporting station to the accident site is located at Phoenix Sky Harbor International Airport about 48 nautical miles northwest of the accident site. The observation taken at 1950 hours local, the evening of the accident, was in part: "3,500 broken, 8,500 overcast, visibility eight in light rain, temperature 49 degrees Fahrenheit, dew point 46 degrees Fahrenheit, wind 060 degrees at 11 knots, altimeter 29.80 inHg." Three hours earlier, at 1657 hours lo ## Aircraft - Registration: [N9MP](https://openairdocs.org/deregistered/N9MP-1999-06-07), registration cancelled 1999-06-07, S/N EA-116 (OpenAirDocs) - Reported make and model: BEECH A-36 - Registry model: [Beech A36TC](https://openairdocs.org/model/beech-a36tc) (registry code 1151603) (OpenAirDocs) - Category: Airplane - Serial number: EA-116 - Airframe hours: 2300 - Engines: CONTINENTAL IO-520-UB 285 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Wasatch New Horizon, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 25, 1993, 133 hours before - Departed: 36U, HEBER, UT - Destination: TUS, TUCSON, AZ ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 46; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: left; flight hours: 2,634 total ## Weather - Conditions: Instrument (IMC), Night/dark - Observed at: TUS, 48 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 19931115042799A](https://openairdocs.org/incident/19931115042799A), Nov 15, 1993: Beech A36, Florence, AZ, Destroyed. Encountered severe icing. Engine quit. On empty tank. Lost control 500 lbs over gross and aft CG. No briefing. 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.