Pilot Debrief

BEECH A36 near Spring Branch, TX — 2009-11-08

Final reportCEN10FA044
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Date
2009-11-08
Location
Spring Branch, TX, USA
Aircraft
BEECH A36
Registration
N91TD
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Climb

Probable cause

The pilot's failure to maintain control of the airplane during cruise flight in instrument meteorological conditions. Contributing to this accident was the pilot’s lack of recent experience in flying in instrument meteorological conditions.

Contributing factors

Contributing to this accident was the pilot’s lack of recent experience in flying in instrument meteorological conditions.

NTSB narrative

The pilot was on an instrument flight rules flight and was level at 9,000 feet mean sea level. Radar data showed that the airplane was flown in an area of heavy intensity rain echoes and was on a meandering course generally eastbound when it then began a shallow turn to the left and then began turning to the right. Radar data for the last 14 seconds of the flight showed that the airplane began a descent and was still turning to the right. Radio and radar contact was then lost. Two witnesses near the accident site reported hearing a loud noise and then seeing something very large with lots of smaller pieces falling out of the clouds. Separated portions of the airplane impacted terrain in a generally circular area about 500 feet in diameter, consistent with an in-flight breakup at a low altitude. A postaccident examination of the airplane showed no anomalies with the engine or other systems. A review of the pilot’s logbook showed that his last instrument flight experience was nearly 2 years prior to the accident. It also showed the pilot had recently purchased the airplane and had approximately 4 hours of flight time in it. A sedating antihistamine with impairing effects was found during a postmortem toxicological examination of tissue from the pilot, but no blood was available for analysis, so no determination could be made regarding how recently the medication might have been taken or whether the pilot could have been impaired by its use at the time of the accident.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have avoided IMC conditions by altering flight path before entering clouds.

NTSB coding

Evidence available

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

Docket documents28

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