# NTSB NYC08FA109: Beech A36, N3815T, Cumberland, MD, February 22, 2008 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 21, 2008, 20:05 local (Feb 22, 2008, 01:05 UTC) - Place: Cumberland, MD - Coordinates: 39.642501, -78.698333 - Nearby events: https://openairdocs.org/map.md?lat=39.6425&lon=-78.6983&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report May 6, 2009 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, FAA/FSDO, Hawker Beechcraft Corporation - NTSB case key (mKey): 67564 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC08FA109 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67564/pdf - Page: https://openairdocs.org/ntsb/NYC08FA109 ## Probable cause The pilot's failure to maintain the proper approach course for undetermined reasons. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech A36, 5 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=1151604), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Ceiling/visibility/precip: clouds](https://openairdocs.org/ntsb-findings/03035025): Environmental issues › Conditions/weather/phenomena · Not specified (probable cause); cases with it: [Beech A36, 3 cases](https://openairdocs.org/ntsb-findings/03035025/cases.md?model=1151604), [All aircraft, 108 cases](https://openairdocs.org/ntsb-findings/03035025/cases.md) - [Light condition](https://openairdocs.org/ntsb-findings/03036000): Environmental issues › Conditions/weather/phenomena · Not specified (probable cause); cases with it: [Beech A36, 1 case](https://openairdocs.org/ntsb-findings/03036000/cases.md?model=1151604), [All aircraft, 15 cases](https://openairdocs.org/ntsb-findings/03036000/cases.md) - [Terrain: mountainous/hilly terrain](https://openairdocs.org/ntsb-findings/03021010): Environmental issues › Physical environment · Not specified; cases with it: [Beech A36, 5 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md?model=1151604), [All aircraft, 329 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Beech A36, 10 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=1151604), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis The pilot was conducting a localizer/distance measuring equipment approach to runway 23, in night instrument meteorological conditions, to an airport that was 775 feet above mean sea level (msl). Radar contact with the airplane was lost while the airplane was inbound on the approach, about 12 miles northeast of the airport at an altitude of 3,700 feet msl. Air traffic control advised the pilot that he was no longer under radar coverage, which he acknowledged. There were no further communications received from the airplane. The airplane impacted 60- to 80-foot-tall trees at the top of a ridgeline that was about 1,240 feet msl, approximately 3.13 miles northeast of the airport. The debris path was oriented about a 110-degree heading, and the airplane came to rest about a 065-degree bearing from the runway. Examination of the wreckage, which was extensively fire- and impact-damaged, did not reveal any preimpact mechanical malfunctions. The pilot was an active Federal Aviation Administration-designated pilot examiner and had about 11,500 hours of total flight experience. A weather observation taken at the airport about the time of the accident included winds from 150 degrees at 6 knots, visibility of 1 1/4 miles, and a 600-foot overcast ceiling. The minimum visibility for the approach was 1 mile and the minimum descent altitude was 1,400 feet msl. ## Factual narrative HISTORY OF FLIGHT On February 21, 2008, about 2005 eastern standard time, a Beech A36, N3815T, was substantially damaged when it impacted terrain while on approach to the Greater Cumberland Regional Airport (CBE), Cumberland, Maryland. The certificated airline transport pilot and the passenger were killed. Instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan had been filed for the flight that originated at the Yeager Airport (CRW), Charleston, West Virginia, destined for CBE. The business flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. According to information obtained from the Federal Aviation Administration (FAA), the airplane departed CRW about 1850, and landed briefly at the Upshur County Airport, Buckhannon (W22), West Virginia, for the pilot to secure an unsecured door, before continuing on to CBE and climbing to a cruising altitude of 5,000 feet mean sea level (msl). At 1948:17, the airplane was cleared for the localizer/distance measuring equipment (LOC/DME) approach to runway 23, a 5,048-foot-long, 150-foot-wide, asphalt runway. The pilot reported inbound on the approach at 2002:34. Due to insufficient radar coverage, radar contact with the airplane was lost at 2003:46, when it was about 12 miles northeast of CBE, at an altitude of 3,700 feet msl. Air traffic control advised the pilot that he was no longer under radar coverage, which he acknowledged. There were no further communications received from the airplane. The airplane was located on February 22, 2008, at 1746, by search and rescue personnel, in a wooded area, on sloped terrain, about 3 miles northeast of the airport. PERSONNEL INFORMATION The pilot, age 76, held an airline transport pilot certificate with an airplane multiengine land rating. He held a commercial pilot certificate with an airplane single-engine land rating and an instrument airplane rating. The pilot was also an FAA designated pilot examiner and held a flight instructor certificate, with ratings for airplane singe-engine, airplane multiengine, and instrument airplane.. According to the pilot's logbook, at the time of the accident he had accumulated about 11,500 hours of total flight experience, of which, 9.7 and 49.1 hours were accumulated during the 30 and 90 days preceding the accident; respectively. Of the total flight experience, about 1,400 hours were logged as in actual instrument meteorological conditions and about 1,000 hours were logged as night flight experience. The pilot logged about 13 and 22 hours as in actual instrument meteorological conditions during the 6 months and 1 year preceding the accident; respectively. He also logged about 5 hours and 10 hours as in night conditions during the 6 months and 1 year preceding the accident; respectively. The pilot held an FAA second-class medical certificate, which was issued on October 1, 2007. AIRCRAFT INFORMATION The airplane was manufactured in 1981, and equipped with a Teledyne Continental Motors IO-550-B5 engine. Review of the airplane's maintenance records revealed that its most recent annual inspection was performed on March 9, 2007. The airplane was equipped with a TKS Ice Protection System, which was installed in June 2003, per a supplemental type certificate. The airplane was also equipped with an Avidyne EX500 multifunction display and a Garmin 430 panel mounted global positioning system, with XM Satellite weather data capabilities. Prior to the date of the accident, the airplane was flown on February 17, 2008, on a roundtrip IFR flight from CBE to Stevensville, Maryland. The pilot of that flight reported that he did not experience, nor was he aware of any anomalies with the airplane. After the flight, he refueled the airplane with 32.7 gallons of 100 low-lead aviation gasoline and "topped-off" the TKS deicing fluid reservoir. METEOROLOGICAL INFORMATION A weather observation taken at CBE, at 2006, reported: wind from 150 degrees at 6 knots; visibility 1 1/4 statute miles; ceiling 600 feet overcast; temperature -6 degrees Celsius (C); dew point -7 degrees C; altimeter 30.31 inches of mercury. AERODROME INFORMATION Greater Cumberland Regional Airport was positioned at 39 degrees, 36 minutes, 55.5 seconds, north latitude; 78 degrees, 45 minutes, 39.1 seconds, west longitude, at an elevation of 775 feet msl. Runway 5-23, was 5,048-feet-long, 150-feet-wide, and constructed of grooved asphalt. Runway 23 was equipped with a localizer/distance measuring equipment (LOC/DME) approach, medium intensity runway edge lighting, and a 4-light precision approach path indicator light system with a 3-degree glide path. Review of the runway 23 localizer\DME approach diagram revealed a minimum descent altitude of 1,400 feet (msl), with a weather minimum of 1 statute mile visibility. The missed approach point was 0.9 miles DME. WRECKAGE AND IMPACT INFORMATION The airplane impacted 60 to 80-foot-tall trees, at the top of a ridgeline that was about 1,240 feet msl, approximately 3.13 miles northeast of the airport. The airplane continued to strike trees for about 1/10 mile, before impacting the ground, and coming to rest inverted, at an elevation of about 1,090 feet msl. The debris path was oriented about a 110-degree heading, and the airplane came to rest about a 065-degree bearing from the runway. A postcrash fire consumed the majority of the wreckage. All major portions of the airplane were accounted for. The entire cockpit and cabin compartment was destroyed by fire. Portions of both wings were extensively fire damaged and contained leading edge crushing. A 7-foot section of the empennage remained, with the rudder and vertical stabilizer attached. In addition, approximately 34 inches of the left elevator remained attached, and the right elevator was intact, except for the counterweight, which had separated and was located along the debris path. Flight control continuity was confirmed from the rudder and elevator control surfaces to the forward cockpit area, and from the forward cockpit area to the left wing root, and the right wing aileron bellcrank. The ailerons remained connected at their respective control surface positions, on both wings. Measurement of the left flap actuator corresponded to a 15-degree flap extended position. The right flap actuator was destroyed. The engine was fire damaged and remained attached to the airframe via cables, hoses, and loose structure. The three-bladed propeller assembly remained attached to the crankshaft flange. The propeller blades displayed evidence of "S"-bending and distortion consistent with rotation at the time of impact. The engine was rotated via an accessory drive gear. Crankshaft continuity was observed through the accessory section. In addition, valve train continuity and thumb compression was attained on all cylinders. A lighted borescope inspection of all cylinders, piston heads and valves also did not reveal any mechanical malfunctions. Both magnetos produced spark from all towers when rotated by hand. The engine-driven fuel pump remained attached and its drive coupling was intact. The mixture control and fuel manifold screens were absent of contamination. The top spark plugs were removed, and their electrodes were intact. The No. 5 and 6 cylinder fuel injectors were impact damaged; however, all fuel injectors were absent of debris. The airplane was equipped with an engine driven and a standby vacuum pump, which were disassembled. Both drive couplings were melted and internal examination of the vanes and rotors did not reveal any preimpact failures. MEDICAL AND PATHOLOGICAL INFORMATION Toxicological testing conducted on the pilot by the FAA Forensic Toxicology Research Team, Civil Aerospace Medical Institute was negative for alcohol, and positive for atenolol present in lung and liver tissue. Atenolol was a beta blocker belonging to a group of drugs u ## Aircraft - Registration: [N3815T](https://openairdocs.org/deregistered/N3815T-2009-12-29), registration cancelled 2009-12-29, S/N E-1805, built 1981 (OpenAirDocs) - Reported make and model: BEECH A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-1805 - Airframe hours: 3127 - Engines: Teledyne Continental Motors IO-550-B5 300 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Business, Part 91 - Operator: Bzm LLC. - Registered owner: Bzm LLC. - Airworthiness certificate: Standard, Utility - Last inspection: Annual, March 9, 2007 - Departed: CRW, Charleston, WV - Destination: CBE, Cumberland, MD - Flight plan: IFR - Airport: CBE, Greater Cumberland Regional, runway 23, 5,048 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 76; injuries: fatal; commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review August 14, 2007; seat: left; toxicology performed; flight hours: 11,465 total, 10,965 as pilot in command, 20 in the last 90 days, 8 in the last 30 days ## Weather - Conditions: Instrument (IMC), Night - Wind: 150° at 6 knots - Visibility: 1.25 statute miles - Lowest ceiling: 600 ft overcast - Temperature: 21 °F, dew point 19 °F - Altimeter: 30.30 inHg - Observed at: CBE, 3 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 20080221013159A](https://openairdocs.org/incident/20080221013159A), Feb 21, 2008: Beech A36, Cumberland, MD, Destroyed, 2 fatal. (-23) While on approach in snowy conditions, the aircraft struck numerous trees on a hilltop approximately 3.25 miles NE of cbe. As a result of the sustained… 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.