Pilot Debrief

BEECH A36 near Rayville, LA — 2023-07-07

Final reportCEN23FA283
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Date
2023-07-07
Location
Rayville, LA, USA
Airport
M79
Aircraft
BEECH A36
Registration
N15RP
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Approach

Probable cause

The pilot’s visual flight rules flight into instrument meteorological conditions, which resulted in a loss of control during the approach to the destination airport and subsequent impact with terrain.

NTSB narrative

The airplane was enroute to the destination airport under visual flight rules and without air traffic control services; radar data showed that it made several turns before approaching the airport from the south. The turns were not consistent with a standard visual airport traffic pattern. The airplane wreckage was located about 1 mile south of the airport. Ground scarring and airplane damage was consistent with a nose-down, high-speed terrain impact with the landing gear extended. Postaccident examination of the airplane and engine revealed no mechanical anomalies that would have precluded normal operation. The accident site was located ahead of a cold front; it had rained earlier in the evening, leading to abundant surface moisture after sunset. High-Resolution Rapid Refresh (HRRR) model sounding for the approximate accident site location and time indicated a conditionally unstable environment from the surface through 200 ft above ground level (agl) then a stable environment from 200 ft agl through 4,000 ft. With a subsidence inversion of approximately 1,600 ft, it is likely fog and low clouds were beginning to form above the accident site at the accident time. Recorded weather observations indicated ceilings down to 200 ft agl and decreasing visibilities below a mile after the accident time. It is likely the accident flight likely encountered instrument meteorological conditions between 200 ft agl and 1,600 ft mean sea level east of Monroe Regional Airport, which was about 13 miles west of the accident site. Based on the variation in measured ethanol levels, the extent of the pilot’s injuries, and the presence of other alcohols, at least some of the detected ethanol likely was from sources other than alcohol consumption. The levels of ethanol in the tested tissue specimens could not be used to reliably determine the pilot’s blood ethanol level at the time of the crash, or to exclude the possibility of alcohol consumption and associated impairment. The postmortem concentrations of delta-9-THC and its metabolite indicate that the pilot had used a cannabis product. However, the precise timing of last cannabis use, and whether associated impairing effects were present at the time of the crash, could not be determined from the toxicological evidence. The toxicology results also indicate that the pilot had used phentermine, but the levels measured in tissues could not be used to establish the presence of associated impairing effects at the time of the crash. Overall, several substances were detected that may cause performance impairment alone or in combination, but no reliable conclusion could be drawn from toxicological evidence about specific effects on the pilot at the time of the crash.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have chosen to divert to M79 instead of continuing approach.

NTSB coding

Evidence available

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

Docket documents11

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