Pilot Debrief

BEECH A36 near Kansasville, WI — 2012-09-09

Final reportCEN12FA617
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Date
2012-09-09
Location
Kansasville, WI, USA
Airport
ENW
Aircraft
BEECH A36
Registration
N3224G
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Climb

Probable cause

In-flight loss of control for reasons that could not be determined because postaccident examination of the pilot and testing of the airplane did not reveal any anomalies that would have led to the loss of control.

NTSB narrative

The airplane was established in cruise flight at 6,000 feet mean sea level on a north-northwest course. Communications between air traffic controllers and the pilot were routine. The pilot did not advise the controllers of any difficulties or anomalies nor did he issue any distress call. About 30 seconds before the accident, the airplane entered a descent that continued until impact. A witness observed the airplane on its north-northwest course before it "tipped forward" and descended into the ground. The airplane appeared to be intact at the time, and she did not recall seeing any flames or smoke before impact. The main wreckage site was about 50 feet in diameter, with debris extending to about 200 feet. The airplane was fragmented; however, portions of both wings, the empennage, and all flight controls were located at the accident site. The postaccident examination did not reveal any anomalies consistent with a preimpact failure or malfunction. The relatively concentrated distribution of the wreckage was not consistent with an in-flight break up. Additionally, the existence of day visual meteorological conditions with clear skies precluded the possibility of spatial disorientation. Toxicology testing noted the presence of ethanol; however, it could not be determined if it was as a result of postmortem production or ingestion. Regardless, the ethanol level noted was not impairing and did not pose a significant hazard to flight safety. A review of the pilot’s Federal Aviation Administration medical file, toxicology testing, and autopsy did not provide evidence of acute medical incapacitation, but the latter were significantly limited by the degree of injury. Considering the abrupt departure from cruise flight and the uninterrupted descent to impact, the possibility of an acute medical problem could not be ruled out.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Pilot could have reported anomalies before losing control.

NTSB coding

Evidence available

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

Docket documents24

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