Pilot Debrief

BEECH V35B near Vancouver, WA — 2022-06-28

Final reportWPR22FA235
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Date
2022-06-28
Location
Vancouver, WA, USA
Airport
VUO
Aircraft
BEECH V35B
Registration
N444PM
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s decision to execute a steep turn to final approach, which resulted in an exceedance of the airplane’s critical angle of attack and an accelerated stall. Contributing to the accident was the improper positioning on base leg and the pilot’s subsequent decision to continue the approach.

Contributing factors

Contributing to the accident was the improper positioning on base leg and the pilot’s subsequent decision to continue the approach.

NTSB narrative

The pilot departed and about 3 minutes into the flight he elected to return to his departure airport due to weather. The airplane entered the downwind leg of the airport traffic pattern and made his final radio transmission over the airport common traffic advisory frequency (CTAF). When abeam the runway threshold the pilot then made an early turn onto base leg of the traffic pattern for reasons that could not be determined, and the airplane descended towards the runway. As the airplane turned onto final approach, just over the runway threshold, it made a right turn about 90° and impacted the ground. The airplane was destroyed by postcrash fire. Postaccident examination of the airplane and engine revealed no preimpact mechanical anomalies that could have precluded normal operation. The weather was not likely a factor in the accident as reports indicated few clouds and visibility was variable but appeared clear in surveillance video. The pilot’s flight experience in the accident airplane make/model are unknown, but he was familiar with the traffic pattern at the airport where the accident occurred. The pilot’s autopsy report showed that he had an increased risk of a sudden incapacitating event due to coronary artery disease. However, a family member noted that the pilot was in good health and showed no indications of distress the morning of the accident flight. In addition, the pilot exhibited no medical concerns during his communications with air traffic control, which ceased about 18 seconds before the accident. Video and radar evidence also indicated the pilot flew a stabilized descent while on the base leg of the traffic pattern, which also suggests he was likely not in distress. In this context, no evidence suggests that a medical anomaly contributed to the accident. As the pilot turned onto final approach, he commanded a steep turn to align the airplane with the runway, which likely resulted in an exceedance of the airplane’s critical angle of attack, an accelerated stall, and impact with terrain. The pilot had an opportunity to go-around after the improper base leg entry, thus his decision to continue the approach following the base leg turn contributed to the accident.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Pilot could have chosen to execute a go-around instead of continuing the approach.

NTSB coding

Evidence available

  • Video
  • ADS-B / radar
  • Photos
  • 20 docket documents
View NTSB final reportView NTSB docket

Docket documents20

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