# NTSB NYC08FA056: Beech H35, N5481D, Warrenton, VA, December 10, 2007 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 9, 2007, 20:50 local (Dec 10, 2007, 01:50 UTC) - Place: Warrenton, VA - Coordinates: 38.624721, -77.753051 - Nearby events: https://openairdocs.org/map.md?lat=38.6247&lon=-77.7531&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report December 28, 2008 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, FAA/AAI-100 - NTSB case key (mKey): 67224 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC08FA056 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67224/pdf - Page: https://openairdocs.org/ntsb/NYC08FA056 ## Probable cause The pilot's failure to follow the published instrument approach procedure and his failure to maintain the minimum descent altitude which resulted in collision with trees and terrain. Contributing to the accident were the night, instrument meteorological conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with object, approach - light condition - night (contributing factor) - weather condition - low ceiling (contributing factor) - procedures/directives - not followed, pilot in command (cause) - minimum descent altitude - not maintained, pilot in command (cause) - object - tree(s) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The pilot was conducting a GPS approach to his home airport, during night, instrument meteorological conditions. The airplane was established on the inbound course, when it crossed the final approach fix at the required crossing altitude (2,200 feet). The airplane then continued a gradual descent until it impacted trees about 4 miles from the airport, on the same heading as the inbound course for the approach. Examination of the airplane and engine revealed no mechanical anomalies. The pilot had accumulated 683 hours of total flight experience, 67 of which were in actual instrument conditions. The pilot completed his most recent instrument proficiency check (IPC) 5 months prior to the accident, during which he performed four instrument approaches in a simulator (none of which included instrument approaches to the destination airport, which was also his home airport). After the IPC, the pilot accumulated 8.4 hours of actual instrument flight time; however, he did not log any instrument approaches. At the time of the accident, weather included overcast clouds at 300 feet, 1 mile visibility, temperature 6 degrees Celsius (C), dew point 6 degrees C. An employee of the fixed base operator at the airport stated that no other aircraft came into the airport on the day of the accident, as it was "very foggy" all day. ## Factual narrative HISTORY OF FLIGHT On December 9, 2007, at 2050 eastern standard time, a Beech H35, N5481D, was substantially damaged when it impacted trees and terrain during an instrument approach to Warrenton-Fauquier Airport (W66), Warrenton, Virginia. The certificated private pilot was fatally injured. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the flight which originated at Allendale County Airport (88J), Allendale, South Carolina, at 1824. The personal flight was conducted under 14 Code of Federal Regulations Part 91. According to family members, the pilot owned homes in Florida and Virginia. On the day of the accident, he was returning from his home in Florida, to attend a meeting for his work the following morning. According to air traffic control (ATC) information provided by the Federal Aviation Administration (FAA), the airplane was being vectored for the global positioning system (GPS) runway 15 approach at W66. When the airplane was 7 miles from the Cassanova very high frequency omni-directional radio (VOR), the controller instructed the pilot to "cross Cassanova at 3,000 feet; cleared for the RNAV/GPS 15 approach." Radar data indicated the airplane crossed the VOR at 3,100 feet, and gradually descended to the initial approach fix, EYAGI, where it turned inbound for the approach at an altitude of 2,700 feet. After crossing EYAGI, the airplane continued a gradual descent to 2,200 feet. Prior to the airplane reaching the final approach fix (LIPIY), the controller stated, "advise canceling I-F-R; frequency change approved." The pilot acknowledged the transmission. The airplane crossed LIPIY at 2,200 feet (2,200 feet was the required altitude for crossing the final approach fix) and continued a gradual descent until the last radar contact was observed at 1,500 feet, approximately 1 mile northwest of the accident site. An alert notice (ALNOT) was issued for the airplane after it was lost from radar, and search and rescue operations were initiated. The airplane was located on December 10, 2007, at 0500, in a heavily wooded area about 4 miles northwest of the airport. PERSONNEL INFORMATION The pilot, age 43, held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent FAA third-class medical certificate was issued August 13, 2007. At that time, the pilot reported 648 hours of total flight experience. An examination of the pilot's logbook revealed he had logged 683 hours of total flight experience. The last entry was dated October 31, 2007, and at that time, the pilot had logged 67 hours of actual instrument time and 35 hours of simulated instrument time. The pilot completed an instrument proficiency check (IPC) on July 23, 2007, during which, he performed four instrument approaches in a simulator, none of which included instrument approaches at W66. Since that date, the pilot accumulated 8.4 hours of actual instrument flight time; however, he did not log any instrument approaches. His most recent instrument approach conducted at W66 was the GPS Runway 14 approach on September 17, 2006. AIRCRAFT INFORMATION According to the airplane and engine logbooks, the most recent annual inspection was completed on May 15, 2007, with no anomalies noted. METEOROLOGICAL INFORMATION The weather reported at the Manassas Regional Airport (HEF), Manassas, Virginia, about 12 miles north of the accident site, at 2046, included winds from 010 degrees at 3 knots, 2 miles visibility, overcast clouds at 400 feet, temperature 6 degrees Celsius (C), dew point 6 degrees C, and an altimeter setting of 30.30 inches of mercury. According to an employee of the fixed base operator (FBO) at W66, no other aircraft landed at W66 on the day of the accident, as it was "very foggy" all day. The employee also stated that the Automated Weather Observing System (AWOS) at W66 reported weather, at 2120, as: overcast clouds at 300 feet, 1 mile visibility, temperature 47 degrees, and dew point 44 degrees. On December 9, 2007, at 1337 and at 1750, the pilot received weather briefings from the Direct User Access Terminal (DUAT) service for his flight. The details of the weather briefings included a stationary front over the pilot’s route of flight, and IFR conditions with rain. AIRMET Sierra was in effect for occasional ceilings below 1,000 feet and visibility less than 3 miles with mist, fog, and precipitation. AIR TRAFFIC CONTROL The minimum vectoring altitude (MVA) for the area that included W66 and four satellite airports, with 14 instrument approaches, was 3,000 feet MSL. The RNAV (GPS) Runway 15 approach was the only approach with an initial approach fix crossing altitude greater than the MVA. The minimum altitude crossing restriction, at the initial approach fix, EYAGI, was 3,600 feet MSL, due to a 1,540-foot obstruction within 4 miles of the holding pattern. The specific airport instrument approach information for W66 was available to the controller that handled N5481D, via the Information Display System (IDS) located at the air traffic control console. Four controllers were interviewed after the accident, three of whom reported having never cleared an aircraft for the RNAV (GPS) Runway 15 Approach at W66. AIRPORT INFORMATION Warrenton Airport had a single, 5,000-foot runway oriented in a 15/33 configuration. The airport had VOR and GPS instrument approaches to runway 15. The inbound course for the RNAV (GPS) Runway 15 Approach was 149 degrees magnetic, and the glideslope crossing altitude was 2,200 feet msl. The decision altitude was 780 feet msl and the airport elevation was 337 feet. WRECKAGE AND IMPACT INFORMATION The initial impact point was the top of a tree, about 80 feet tall. The wreckage path continued on an approximate 150-degree magnetic heading, with tree strikes observed at progressively lower heights, for about 100 yards. All three landing gear, the left ruddervator, and three separated sections of the left wing were observed along the wreckage path. The sections of the left wing were severely impact damaged and contained tree bark transfer and small branches embedded in the wing sections. The airplane came to rest in a vertical, nose-down attitude, at the base of a tree, in the direction of the wreckage path. The right wing remained attached to the fuselage at the wing root, and the right aileron and flap remained attached to their respective attachment points. The empennage remained attached to the fuselage and the right ruddervator remained attached, and relatively intact. Flight control continuity was confirmed from the right aileron to the cockpit and from the cockpit to the separated left wing sections. The ends of the aileron cables at the left wing separation point displayed fractures consistent with overstress separation. Flight control continuity was also confirmed from the cockpit to the ruddervator. The throttle control and mixture control were observed approximately 1 inch aft of the forward position, and the propeller control was observed in the forward position. The fuel selector was selected to the right tank, and the landing gear dial was selected to the down position. The manifold pressure gauge read 29 inches, the heading indicator read 150 degrees, the altimeter read 100 feet, and 30.28 was set in the Kohlsman window. The engine remained attached to the firewall and the propeller remained attached to the engine. Examination of the propeller blades revealed S-bending and chordwise scratching. The engine was removed from the airplane and further examined at a salvage facility. Results of the examination revealed that when the crankshaft was rotated by the propeller, valve train continuity was confirmed to all cylinders. The cylinders were examined with a lighted borescope, and no anomalies were noted. The top spark plugs were removed and the ## Aircraft - Registration: [N5481D](https://openairdocs.org/deregistered/N5481D-2010-02-11), registration cancelled 2010-02-11, S/N D-4988, built 1957 (OpenAirDocs) - Reported make and model: BEECH H35 - Registry model: [Beech H35](https://openairdocs.org/model/beech-h35) (registry code 1151520) (OpenAirDocs) - Registry engine: [Continental O-470 series](https://openairdocs.org/engine/continental-o-470-series) (registry code 17026, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-4988 - Airframe hours: 5907 - Engines: Contl O-470 240 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Hugh Bryant - Registered owner: Hugh Bryant - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 1, 2007 - Departed: 88J, ALLENDALE, SC - Destination: W66, Warrenton, VA - Flight plan: IFR - Airport: W66, Warrenton-Fauquier Airport, runway 14, 5,000 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 43; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review June 1, 2006; seat: left; toxicology performed; flight hours: 683 total, 30 in the last 90 days ## Weather - Conditions: Instrument (IMC), Night - Wind: 10° at 3 knots - Visibility: 2 statute miles - Lowest ceiling: 400 ft overcast - Temperature: 43 °F, dew point 43 °F - Altimeter: 30.29 inHg - Observed at: HEF, 12 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 20071209829479A](https://openairdocs.org/incident/20071209829479A), Dec 9, 2007: Beech H35, Warrenton, VA, Destroyed, 1 fatal. (-23) On December 9, 2007, at approximately 2050 EST, a single engine Beech bonanza, model H-35, N5481D, serial number D-4988, registered to the pilot [privacy… 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.