1 fatality

28 Sep 2008: BEECH A36 (N82TB) — Carlsbad, CA

Carlsbad, CA, United States

On 28 Sep 2008, a BEECH A36 (registration N82TB) was involved in an aviation accident near Carlsbad, CA. One person was killed. Investigators recorded the probable cause as: The pilot's failure to maintain control during the instrument approach and attempted go-around. This summary draws on records from NTSB; 12 related events involving the same aircraft type or operator are linked below.

SourcesNTSBPrimary reportUpdated 1778583330Data APIEditorial standards

On September 28, 2008, a Beechcraft A36 impacted terrain during an instrument approach to McClellan-Palomar Airport. The pilot was killed and the aircraft was destroyed. Low visibility and fog prevailed.

History of the Flight

On September 28, 2008, about 0715, a Beechcraft A36 (N82TB) impacted terrain while on an instrument approach to McClellan-Palomar Airport in Carlsbad, California. The instrument-rated private pilot operated the aircraft under Part 91. The pilot was killed and the airplane was destroyed. Instrument meteorological conditions prevailed, and an IFR flight plan had been filed. The flight originated from Lake Havasu City Airport, Arizona.

The pilot filed an IFR flight plan at 0351 using the FAA Direct User Access Terminal (DUAT) system. The plan specified an intended departure at 0550 and destination at McClellan-Palomar, with no alternate airport designated.

Air traffic control communications and radar data showed the airplane on the ILS approach for runway 24. At 0711:14, the tower advised that runway visual range (RVR) was 1,600 feet (1/4 mile), winds from 280 degrees at 5 knots, and cleared the pilot to land. At 0713:52, a low altitude alert was issued; at 0714:58, the pilot was notified he appeared south of course. At 0715:16, the pilot transmitted he would ‘abort’ the approach, and at 0716:06, he said ‘I’m in trouble.’ No further communications were established.

Radar data indicated that at 0714:41, two miles from the runway, the airplane crossed the final approach course at 800 feet msl heading south. At 0715:09, a tight left turn began with altitude fluctuating between 600 and 1,100 feet. The last radar return at 0716:04 showed the airplane at 900 feet msl and a ground speed of 56 knots. The wreckage was located on a hillside 1.3 miles southeast of the runway end, near the last radar return.

Personnel Information

The 41-year-old pilot held a private pilot certificate with single-engine land and instrument ratings, issued June 7, 2008. His third-class medical certificate was issued November 9, 2005, with no limitations. His flight logbook was not recovered; insurance records showed he reported 899.5 total hours as of July 28, 2008, including 41.0 hours actual instrument, 6.6 simulated instrument, and 11.1 hours in complex airplanes—all in the accident airplane between July 24 and 29. No instrument approaches or instrument time were logged in that period. The CFI who provided complex training did not give instrument instruction. The primary CFI noted the pilot was proficient with a VistaNav (AV8OR) electronic flight bag and had mentioned landing at an airport at approach minimums.

Aircraft Information

The low-wing, retractable-gear Beechcraft A36 (serial number E-1216) was built in 1978. Originally six seats, only four were found. It had a Teledyne Continental IO-550-B(4) 300-hp engine and a three-blade constant-speed propeller. The most recent annual inspection was completed July 12, 2008, at 485.5 engine hours and 3,836.5 airframe hours. Empty weight was 2,459.9 pounds per the weight and balance sheet.

Meteorological Information

At 0353, when the flight plan was filed, the Palomar ASOS reported visibility 1/2 mile in fog, vertical visibility 100 feet, calm winds. At 0653, visibility was 1/4 mile in fog, vertical visibility 100 feet, winds 350° at 3 knots. At 0711, the tower reported RVR 1,600 feet, winds 280° at 5 knots. The published minimums for the ILS runway 24 approach were 200-foot ceiling and 3/4-mile visibility. At 0753, ASOS reported 1/4 mile visibility and 100-foot ceiling.

Wreckage and Impact

The wreckage was on a 40-degree hillside with dry brush and grass. The entire airplane was at the initial impact point and consumed by post-impact fire. All flight controls were accounted for; cables were traced except in the cockpit where thermal damage prevented verification. The propeller separated from the crankshaft, with two blades showing S-bending and tip curling. The engine was present with all cylinders; oil pan appeared melted.

Examination revealed the left flap actuator extended 5 inches (20° flaps), elevator trim at 1 7/16 inches (5° tab down), landing gear retracted, fuel selector on right tank. The attitude gyro had two witness marks. The vacuum pump rotor was fractured into four sections with loose vanes. The magnetos did not produce spark due to thermal damage, but spark plugs showed normal light gray color. The engine could not be rotated due to crankshaft bearing deformation; borescope showed no mechanical damage to cylinders, pistons, or valves.

Medical and Pathological Information

An autopsy on September 29, 2008, found multiple blunt force injuries as the cause of death. Forensic toxicology detected ethanol in blood, urine, brain, and muscle; n-propanol in blood, urine, and muscle; no other drugs were found.

Contributing factors

Causes

Performance/control parameters — Not attained/maintainedPilot

Other contributing factors

Effect on operation