Pilot Debrief

BEECH A36 near Carlsbad, CA — 2008-09-28

Final reportLAX08FA300
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Date
2008-09-28
Location
Carlsbad, CA, USA
Airport
KCRQ
Aircraft
BEECH A36
Registration
N82TB
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot's failure to maintain control during the instrument approach and attempted go-around.

NTSB narrative

The airplane was on an Instrument Landing System (ILS) approach to Runway 24. The reported weather was 100-foot ceiling and 1/4-mile visibility in fog at the airport. The published weather minimums for the ILS 24 approach are 200-foot ceiling and 3/4-mile visibility. The tower controller relayed to the pilot that the runway visual range was 1,600 feet (1/4 mile), winds were 280 degrees at 5 knots, and the flight was cleared to land on Runway 24. About 2 minutes later the tower controller issued the pilot a low altitude alert, followed by a notification that it appeared that the pilot was south of course. About 2 minutes later, the pilot transmitted that he was going to ‘abort’ the approach. The pilot's last transmission 1 minute later stated "I’m in trouble." Despite numerous attempts, no further communications with the pilot were established. Radar data indicated that, 2 miles from the approach end of Runway 24, the airplane crossed over the final approach course at 800 feet msl (mean sea level) heading south. The track started a tight left-hand turn with altitude readings that fluctuated between 600 and 1,100 feet msl. The last radar return depicted the airplane at 900 feet msl and at a ground speed of 56 knots. The airplane wreckage was confined to the initial impact point, located on an approximate 40-degree sloping hillside, 1.3 miles southeast of the approach end of Runway 24, in the same vicinity as the last radar return. Post accident inspection of the airframe and engine found no evidence of a mechanical failure or malfunction. The pilot had received his instrument rating 2 months prior to the accident, and had accumulated approximately 41 hours of actual instrument time. Approximately 11.1 hours of dual instruction had been accumulated in the accident airplane. The pilot received no instrument flight training in the accident airplane.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have aborted approach earlier after low altitude alert.

NTSB coding

Evidence available

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

Docket documents22

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