Pilot Debrief

BEECH G35 near South Easton, MA — 2008-08-12

Final reportMIA08FA163
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Date
2008-08-12
Location
South Easton, MA, USA
Airport
BOS
Aircraft
BEECH G35
Registration
N4615D
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Approach

Probable cause

The pilot's failure to maintain control of the airplane while attempting to execute an instrument approach in instrument meteorological conditions. Contributing to the accident was the pilot's lack of instrument currency.

Contributing factors

Contributing to the accident was the pilot's lack of instrument currency.

NTSB narrative

The instrument rated pilot was a volunteer pilot for a charity organization that connects pilots and aircraft owners with individuals in need of transportation primarily for medical purposes. The pilot was not instrument current. In addition, the charity did not verify instrument currency of volunteer pilots nor were they required to. After takeoff, the flight proceeded towards the destination airport on an instrument flight rules clearance and was vectored onto the downwind and base legs for sequencing. The pilot made two errors related to incorrect heading changes both of which were not immediately detected by the controller, but neither were significant. While on the base leg and approximately 1.5 miles west of the final approach course for runway 4R, the controller instructed the pilot to fly heading 060 degrees to intercept the final approach course. Radar data depicted a large radius turn towards the left, and the airplane flying through the final approach course. When the flight was approximately 1.6 miles east of the final approach course, the controller advised the pilot he had passed through the course and instructed him to turn to a heading of 010 degrees to re-intercept. Radar depicted a tight radius turn past the assigned heading, while the airplane descended below the assigned altitude of 3,000 feet. The airplane then turned to the north, then southeast with altitude deviations descending so low the controller issued several low altitude alerts. The airplane then entered a final descent, immerged from the base of clouds, and impacted into a parking lot. Examination of the engine, airframe, and avionics did not reveal any preimpact failures or malfunctions.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Pilot failed to maintain correct heading and altitude during approach.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • Photos
  • 33 docket documents
View NTSB final reportView NTSB docket

Docket documents33

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