Pilot Debrief

BEECH A36 near Eagle Pass, TX — 2009-12-09

Final reportCEN10FA069
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Date
2009-12-09
Location
Eagle Pass, TX, USA
Airport
5T9
Aircraft
BEECH A36
Registration
N1105N
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot's decision to continue the approach below minimums without visual references, and subsequent collision with the perimeter fence/terrain.

NTSB narrative

While on an instrument approach to the non-towered airport, the airplane collided with the airport's perimeter fence and terrain. The fence and perimeter road were parallel to, and about 750-feet east of the runway. The last radar plot was at an altitude of 1,200 feet MSL (Mean Sea Level), but slightly east of the runway, and approximately 435 feet from the accident site. About 30 minutes after the accident, deputies reported that the weather was "foggy". The instrument approach that the pilot was following was the RNAV (GPS) 31. The published minimums for this instrument approach are a 400-foot ceiling and one-mile visibility. The automated weather station about 33 miles northwest of the accident site reported at 0552, calm winds, temperature 41 degrees Fahrenheit, dew point 41 degrees Fahrenheit, visibility less than 1/4 miles (and a Runway visual range ( RVR) of 600 feet variable to 1200 feet) in fog and an indefinite ceiling, altimeter pressure setting 29.85 inches of Mercury. An examination of the airplane failed to reveal any anomalies with the airframe, structure, or systems. The airplane's engine was removed from the airframe and placed in an engine test facility. An engine test run was conducted and the engine was able to produce rated horsepower, without hesitation or interruption. Under the conditions at the time, the pilot appeared to have mistaken the east perimeter road for the runway landing point.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have aborted the approach due to low visibility conditions.

NTSB coding

Evidence available

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

Docket documents13

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