Pilot Debrief

BEECH A36 near Flat Rock, NC — 2009-09-10

Final reportERA09FA514
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Date
2009-09-10
Location
Flat Rock, NC, USA
Aircraft
BEECH A36
Registration
N888WD
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s attempt to maintain visual flight during instrument meteorological conditions, resulting in controlled flight into mountainous terrain. Contributing to the accident was the pilot’s failure to advise the controller of the weather conditions encountered, and his failure to request minimum safe altitude warning (MSAW) monitoring before departure.

Contributing factors

Contributing to the accident was the pilot’s failure to advise the controller of the weather conditions encountered, and his failure to request minimum safe altitude warning (MSAW) monitoring before departure.

NTSB narrative

Although the pilot was instrument rated, the investigation found no record that his rating was current. The pilot advised the air traffic controller before departure that he did not want to execute any instrument landing system (ILS) approaches even though they were in use at the time, and neither transceiver was configured to the localizer frequency. Due to the mountainous terrain surrounding the airport, local air traffic control (ATC) had designated certain mode 3 transponder codes that inhibit minimum safe altitude warning (MSAW) processing for a controller. This was accomplished to prevent repeated nuisance alarms for aircraft operating under visual flight rules (VFR) and not requesting MSAW processing. The pilot did not request MSAW monitoring before departure or at any time during the flight; therefore, the assigned VFR transponder code (0210) inhibited the MSAW. The pilot departed the flight with a reported ceiling of 1,500 feet and 10 miles visibility before proceeding south of the departure airport and electing to return, remaining in constant contact with ATC. While operating only several hundred feet above mountainous terrain, in instrument flight rules conditions due to fog, the pilot did not advise the controller of the weather encountered. While being vectored towards the airport, the airplane impacted trees then terrain at an elevation of approximately 2,809 feet mean sea level. The pilot made no distress call and the controller did not provide a MSAW warning to the pilot. Postaccident examination of the airplane, engine, and engine systems revealed no evidence of preimpact failure or malfunction. While testing of avionics revealed that the “Trim” light bulbs of the autopilot remote mode annunciator and the autopilot and flight director computer were illuminated at the moment of impact, the left pitch trim actuator was found in the neutral position and the circumstances of the accident do not support a pitch trim malfunction. Additionally, the autopilot was not activated at the moment of impact.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot could have requested MSAW monitoring before departure.

NTSB coding

Evidence available

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

Docket documents29

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