LAX96FA042

During arrival after nightfall, the pilot was provided vectors for an ILS Runway 32 Approach to Arcata, CA. He was instructed to intercept the localizer at or above 6,000 feet, then he was cleared for the approach. Radar contact with the airplane was lost about 22 miles from the airport. Subsequently, the airplane crashed on mountainous terrain at an elevation of about 2200 feet. During investigation, radar data showed that the airplane was inbound on the ILS approach, slightly left of the localizer centerline. After about 1 minute, it began a uniform left turn of about 30 degrees, followed immediately by an equally uniform right turn. The radius of the right turn began to decrease until the aircraft disappeared from radar after about 270 degrees of turn. The wreckage was found in proximity of the last radar return. No preimpact mechanical failure was noted during examination of the wreckage, although the airplane was destroyed during impact. Another person, who had flown with the pilot as he practiced instrument flight procedures, noted that on occasions, the pilot turned the wrong way; and at times, also gave the impression of having difficulty in maintaining aircraft control.

History of flight

On November 8, 1995, at 1748 hours Pacific standard time, a Beech Bonanza S-35, N8920M, collided with terrain after being cleared for the ILS RWY 32 approach to the Arcata, California, airport. The aircraft was destroyed and the instrument rated private pilot and his three passengers received fatal injuries. The aircraft was being operated as a personal flight by a private owner when the accident occurred. The flight originated in Oakland, California, about 1620 on the same day. Instrument meteorological conditions prevailed at the time and an IFR flight plan was filed but not activated.

Prior to departure, the pilot received an in-person weather briefing and filed an IFR flight plan for a flight from Oakland to Arcata. Before takeoff the pilot requested a VFR departure in lieu of an IFR release. While en route to his destination, however, the pilot contacted Seattle air route traffic control center (ARTCC) and requested an en route IFR clearance to his destination. The pilot was vectored to intercept the approach course and had been cleared for the ILS runway 32 approach at Arcata when radar and radio communications were lost at 1748.

A witness standing approximately 300 yards from the accident site reported hearing the aircraft engine accelerate just before hearing the sound of what he thought could have been a crash. Another witness driving in his truck about 250 yards from the site reported seeing aircraft lights through a break in the tree line. He stated that because of darkness he was unable to see the aircraft itself. (A record of these interviews is appended to this report.)

Both witnesses described the weather conditions at the time of the accident as foggy with misting precipitation. They also said they could not see any stellar illumination through the existing cloud cover. According to a sun and moon illumination table, the accident occurred during nautical twilight. (A sun and moon illumination computation is appended to this report.)

ARTCC radar data revealed that the aircraft had been tracking about 0.5 miles left of course for about 1 minute paralleling the Arcata localizer on a magnetic course of 315 degrees. The aircraft position was southeast of Knees and northwest of Yeager intersections. While descending from 8,000 feet msl, the aircraft turned left about 30 degrees which was followed immediately by a right turn of approximately 270 degrees. During the latter portion of the right turn the radius of turn began to decrease until approximately 12 seconds later the aircraft disappeared from radar. The aircraft wreckage was found in proximity to the final radar return. The final radar return reported an encoded altitude of 5,700 feet msl at north latitude 40 degrees 38 minutes 32 seconds and west longitude 123 degrees 51 minutes 52 seconds. The ILS approach specifies crossing the Knees intersection inbound at no lower than 5,200 feet msl. (Radar data and ILS RWY 32 approach plate are appended to this report.)

Personnel information

According to FAA Airman Records, the pilot was certificated and rated to conduct a not-for-hire instrument flight in this category and class of aircraft.

A review of the pilot's logbook revealed four series of instrument approaches flown during May, 1995. Although the complete entries were difficult to read, the legible portions indicate at least six instrument approaches had been performed. On July 18, 1995, the pilot made an entry indicating that he had performed a VOR check and had met his night currency reqirement with six full stop landings. In addition, the pilot logged approximately 99 hours of actual instrument time, 148 hours of simulated instrument time, and 41 hours of simulator time. The pilot also had logged approximately 11 hours of actual instrument time since May 4, 1995.

The flight instructor who administered the pilot's last biennial flight review was interviewed by telephone. He described the pilot's performance as being very meticulous. He said the pilot satisfactorily performed steep turns, slow flight, stalls, and simulated emergencies with only one engine operative including Vmc demonstrations with the critical engine inoperative. (A record of this telephone conversation is appended to this report.)

According to the pilot's logbook, on May 4, 1995, he flew 2.5 hours with a safety pilot. During that flight he logged 2.5 hours (hooded). The safety pilot was interviewed by telephone and noted the following discrepancies which occurred during the flight. He stated that while under the hood the pilot did not verify identifiers when tuning navigational aids and that he sometimes turned in the wrong direction. He also reported that although the pilot had undergone what he described as comprehensive instrument training, at times he felt the pilot was only marginally in control of the aircraft. Overall he reported that he believed the pilot had control problems when flying in IFR conditions but that he was conscientious and worked very hard on developing and maintaining his piloting skills. (A record of this telephone conversation is appended to this report.)

One of the passengers was a non-instrument rated, certificated private pilot who, according to a letter found in the aircraft wreckage, was onboard for familiarization purposes. Although all four seats were found and identified, it was not determined where the pilot-rated passenger had been seated at the time of the accident. All four occupants had been ejected from the aircraft and the physical evidence established the two left side occupants. (A copy of this letter is appended to this report.)

Aircraft information

According to current FARs, the aircraft delivery documents, subsequent aircraft, engine and propeller logbook entries, and from the FAA inspectors who inspected these documents, the aircraft was equipped for flight under instrument conditions. A static system check was last completed on March 15, 1995.

The aircraft maintenance records which were reviewed by FAA airworthiness inspectors showed that all applicable airworthiness directives (AD's) had been recorded as having been completed. (A statement from an FAA FSDO airworthiness inspector is appended to this report.)

According to the aircraft logbook, FAA form 337 and STC SA5209SW-D, the aircraft was equipped with an S-Tec System 50 model ST-186-50 with an S-Tec 6406 directional gyro. (S-Tec supplement to POH, FAA Form 337, STC and equipment list with revised weight and balance are appended to this report.)

Because of the uncertainty of the occupants location on the right side of the aircraft, the manufacturer's representative computed several weight and balance scenarios. All the scenarios were found to be within the prescribed limits for weight and balance although the center of gravity was near the aft limit. (Weight and balance computation worksheets are appended to this report.)

Meteorological information

Prior to issuing the pilot a clearance to fly radar vectors to join the Arcata runway 32 localizer, Seattle Center advised the pilot that the 1659 weather at Arcata was: Sky partially obscured, measured 500 feet broken, 1500 feet broken; 0.75 miles visibility with light rain and fog; temperature 59 degrees Fahrenheit, dew point 58 degrees; winds from 160 degrees at 10 knots; altimeter setting 30.04 inches of mercury; runway 32 runway visual range (RVR) 6000 feet plus with fog obscuring 0.3 of the sky.

Aids to navigation

The Arcata airport has an established ILS approach. The approach in use at the time of the accident was the Arcata ILS runway 32 approach. The Arcata ILS approach localizer is aligned on a 316-degree magnetic course to the approach end of runway 32 with a decision height (DH) of 418 feet msl on a descent angle of 3 degrees. There are two fan markers associated with the approach: a middle marker at .04 nautical miles from