# NTSB LAX97FA049: Beech 95-C55, N3774Q, San Diego, CA, November 22, 1996 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 21, 1996, 16:36 local (Nov 22, 1996, 00:36 UTC) - Place: San Diego, CA - Coordinates: 32.549789, -117.040779 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.5498&lon=-117.0408&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report March 31, 1998 - Report: Approved by Office Director - NTSB case key (mKey): 29592 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX97FA049 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/29592/pdf - Page: https://openairdocs.org/ntsb/LAX97FA049 ## Probable cause the pilot's lack of situational awareness (becoming lost/disoriented during the approach), his failure to fly the approach as charted, and his failure to maintain aircraft control, while attempting an abrupt turn toward the airport, which led to an inadvertent stall/spin. The pilot's lack of recent instrument experience was a related factor. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, missed approach (ifr) - weather condition - low ceiling - weather condition - below approach/landing minimums - ifr procedure - not followed, pilot in command (cause) - lack of recent instrument time, pilot in command (contributing factor) - became lost/disoriented, pilot in command (cause) - maneuver - attempted, pilot in command - aircraft control - not maintained, pilot in command (cause) - stall/spin - inadvertent, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled ## Analysis The pilot (plt) got 2 weather (wx) briefings & was advised of deteriorating IFR wx in the destination area. When he filed an IFR flight plan, he told the briefer that he did not have his charts; the briefer looked up the airway designations & fixes for the plt. Near the destination, TRACON told the plt the airport (arpt) was below minimums, & that 3 aircraft (acft) had made missed approaches without seeing the ground. The controller then suggested nearby arpts that were above approach minimums as alternates. The plt said his car was parked at the arpt, & he wanted to make the approach. Radar data disclosed the acft flew the approach segments at least 1,000 higher than the charted altitudes at speeds between 180 & 155 kts. The acft overflew the missed approach point & arpt, then crossed the adjacent US/Mexico border before ATC could instruct the plt to make an immediate missed approach. The plt responded on the radio 'I guess I don't know where I am.' Radar data showed the acft climbing & descending rapidly as it reversed course, then descend to 300 ft agl as it neared the west arpt boundary. The plt transmitted that he thought he had the arpt in sight. Four seconds later, the acft impacted the departure end of the runway. Ground witnesses observed the acft in cloud bases, & they noted that it narrowly missed a building; it then turned sharply toward the runway before descending steeply to ground impact. The pilot's logbook did not show that he had met instrument currency requirements of 14 CFR 91. ## Factual narrative HISTORY OF FLIGHT On November 21, 1996, at 1636 hours Pacific standard time, a Beech 95-C55, N3774Q, collided with the approach end of runway 8L at Brown Field, San Diego, California, while attempting a circling instrument approach to runway 26R. The aircraft was owned and operated by the pilot. Instrument meteorological conditions prevailed and an IFR flight plan was filed for the personal cross-country flight. The aircraft was demolished in the impact sequence and postcrash fire. The instrument rated private pilot, the sole occupant, sustained fatal injuries. The flight originated at Imperial, California, on the day of the accident at 1545 as a flight to San Diego. Records maintained at the San Diego AFSS disclosed that the pilot (using the aircraft registration number) contacted the facility twice for weather information. In the first morning call, the pilot requested an outlook briefing for a flight in the afternoon. Recordings of the telephone conversation note that the pilot was given the outlook that IFR conditions prevailed, VFR flight was not recommended, and that the forecast conditions in the San Diego area were expected to be 500 scattered with ceilings 1,000 feet. The pilot was advised to call after 1300 when an updated forecast would be available. At 1538, the pilot telephoned San Diego AFSS, filed an instrument flight rules flight plan and requested a full weather briefing for the proposed flight. Review of the recorded conversation disclosed that he was advised that the current Brown Field weather included a visibility of 2 miles, with a 900-foot broken ceiling and the expectation that conditions would deteriorate (the VOR-A approach is the only one at Brown Field and the minimums are a visibility of 2 3/4 mile). At the conclusion of the full briefing, the specialists noted that the visibility at the San Diego area airports varied from 5/8 mile to less than 3, and ceilings were from 200 feet at the lowest to the 900-foot report from Brown, which was the highest. The briefing specialists also noted that it was "raining like crazy all over." During the telephone conversation in which the pilot filed his flight plan, he told the FSS briefing specialists that he did not have his charts with him. The FSS specialists had to look up all the airway and fix designations for the pilot's route as he described it. After completing the en route portion of the instrument flight, the pilot was cleared for the VOR-A approach to Brown Field, circle to land runway 26R by the Southern California TRACON. According to the approach chart, the minimums for the approach are a minimum descent altitude of 1,220 feet (700 agl) and a visibility of 2 3/4 miles. Just prior to issuing the approach clearance, the controller told the pilot that the last three aircraft that tried the approach into Brown executed missed approaches without ever seeing the ground. The controller then asked the pilot "where do you want to go after the missed." The pilot responded that he didn't know where to go. In the subsequent exchange, the pilot said that his car was parked at Brown. The controller then gave the pilot the weather at the surrounding airports, noting which ones were below minimums. The pilot selected Lindbergh Field as his alternate choice, but also told the controller that he could not reach his charts and might need some help to get on the approach. The controller reassured the pilot that they would get him set up. Review of the recorded air-to-ground communications tapes revealed that at initial contact with the Brown Field Air Traffic Control Tower (ATCT), the local controller instructed the pilot to report the Poggi VOR (missed approach point), and reminded the pilot that the airport weather was "measured ceiling 300 feet, visibility less than a mile." The pilot responded "how far down can I go." The local controller said that he did not know how far down the pilot could go and restated that the weather was 300 overcast. In response, the pilot said "oh I got it I'll go down to about eight." At 1633:07, the pilot called the tower and stated he was about 2 miles north of Poggi, to which the controller responded that the pilot should report Poggi and executing the missed approach. One minute later, the TRACON facility called the ATCT on the land line and told the local controller that radar showed the aircraft 5 miles south of the airport in Mexican airspace (the airport is on the international border), and to instruct the aircraft to make a missed approach. The local controller immediately advised the pilot of his location and to make an immediate right turn. The pilot responded with "I guess I don't know where I am." Fifty seconds later the pilot stated "I think I'm over the field." The aircraft impacted the end of the runway 4 seconds later. The engines were found buried 18 inches into the asphalt at a 35-degree angle. Ground witnesses reported that the aircraft nearly collided with the top of a convenience store located just off the southwestern corner of the airport as it flew northward at very low altitude. A second witness located in a junk yard about 300 yards off the departure end of runway 26R stated he heard the aircraft fly over "very low and very loud," then caught a glimpse of a "shadow airplane shape in the clouds" as it turned "very steeply on a wing tip" toward the runway. A few seconds later the aircraft hit the ground and exploded. Recorded radar data was obtained from the Southern California Terminal Radar Approach Control (TRACON) and plotted using the commercial computer software Radar View. Both the raw data and the plotted charts are appended to this report, in addition to the VOR-A approach chart for Brown Field. The aircraft's position and mode C reported altitude versus time were compared to the approach chart. The following table illustrates the aircraft's reported altitude at the various fixes in comparison to the minimum charted values for the identified segment (it should be noted that the VOR is the missed approach point): (5.9nm) (4.4nm) (2.3nm) IAF to FAF to VOR to AIRPORT Min Charted Alt /------2,400------/--------1,220------/---------1,220------------/ A/C Mode C Alt 3,200 3,000 2,700 2,300 Detailed review of the radar data from the point the aircraft crossed over the airport at 1634:39 until the last return at 1636:09 disclosed the following mode C altitude reports (dashed line indicates no altitude return): TIME ALTITUDE REMARKS 1634:39 2,100 Over airport 1634:41 2,100 1634:46 2,000 G/S averages 155kts 1634:50 1,900 1634:55 2,200 Told entering Mexico by ATC and to execute missed approach 1635:00 ------ 1635:04 ------ G/S computed at 75kts 1635:09 3,100 Told to turn right by ATC 1635:13 ------ 1635:18 3,100 1635:23 ------ 1635:28 ------ 1635:32 ------ 1635:35 1,600 A/C has reversed course 180 degrees in a 0.2nm radius right turn from the last return to this. 1635:37 1,600 1635:39 2,300 1635:41 ------ 1635:46 2,800 1635:51 ------ 1635:55 2,100 1636:00 1,100 1636:02 800 Target is just south of the runway 26R departure end. 1636:04 800 Transmits "I think I'm over the field." 1636:09 1,000 Last mode C return. Time on transcript that Ground Controller announces crash. PERSONNEL INFORMATION The pilot was a 63 year-old retired physician, who had been an FAA designated Aviation Medical Examiner. Review of the FAA ## Aircraft - Registration: [N3774Q](https://openairdocs.org/deregistered/N3774Q-2015-04-30), registration cancelled 2015-04-30, S/N TE-320, built 1967 (OpenAirDocs) - Reported make and model: Beech 95-C55 - Registry model: [Beech 95-C55](https://openairdocs.org/model/beech-95-c55) (registry code 1152708) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TC-320 - Airframe hours: 1398 - Engines: Continental IO-520-C 285 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Earl A. Bauer, Md, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 1, 1996, 12 hours before - Departed: IMP, IMPERIAL, CA - Destination: SDM - Flight plan: IFR - Airport: SDM, Brown Field, runway 26R, 7,999 × 200 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 547 total, 265 in this make and model, 464 as pilot in command, 9 in the last 90 days, 7 in the last 30 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 200° at 4 knots - Visibility: 0.5 statute miles - Lowest ceiling: 300 ft overcast - Temperature: 75 °F, dew point 73 °F - Altimeter: 29.00 inHg - Observed at: SDM ## 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 19961122036169A](https://openairdocs.org/incident/19961122036169A), Nov 22, 1996: Beech 95C55, San Diego, CA, Destroyed, 1 fatal. Attempted circle land after mixed up VOR approach below minimums. Exploded on ground impact. Severe artery disease. ## Other investigations on N3774Q (1) 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. - [NTSB UNK74X0110](https://openairdocs.org/ntsb/UNK74X0110), May 31, 1974: Beech 55 (N3774Q), Tsuniah Lk, Canada, substantial damage 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.