Pilot Debrief

BEECH 95 C55 near Mountain Ranch, CA — 2017-06-09

Final reportWPR17FA125
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Date
2017-06-09
Location
Mountain Ranch, CA, USA
Airport
O22
Aircraft
BEECH 95 C55
Registration
N3717Q
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Descent

Probable cause

The pilot's continued visual flight rules flight into instrument meteorological conditions and mountain obscuration that resulted in controlled flight into trees and terrain.

NTSB narrative

The instrument-rated commercial pilot departed on a 46-nautical-mile visual flight rules (VFR) flight in the multiengine airplane. Radar data indicated that, as the airplane approached the destination airport at an altitude about 500 ft above ground level, it turned northwest and climbed and appeared to be heading toward a nearby airport. The airplane then entered a right turning descent. The final radar target associated with the airplane was at 3,649 ft mean sea level (about 700 ft agl) about 1 nautical mile north of the accident site. The pilot received two weather briefings before departing on the accident flight, the second about 45 minutes before departure. During the second briefing, the pilot was provided AIRMETs Tango and Sierra for moderate turbulence and mountain obscuration due to clouds and mist, valid for the route of flight and the area of the destination airport. The pilot was also advised during this briefing that VFR flight was not recommended. Review of weather information revealed the presence of multiple cloud layers in the area of the accident site around the time of the accident, including scattered clouds at 1,600 ft above ground level (agl), a broken ceiling at 2,900 ft, and an overcast ceiling at 6,500 ft. Despite the forecasts indicating marginal VFR conditions for the destination airport, the pilot chose to depart and continue into an area of low cloud ceilings and rising terrain. It is likely that, while maneuvering at low altitude, the terrain was obscured or the pilot's in-flight visibility was limited by the cloud conditions, which resulted in controlled flight into terrain. Witness marks in the trees and damage to the airplane were consistent with a controlled flight into terrain event. The airframe and engine examination revealed no mechanical anomalies that would have precluded normal operation. The toxicology report yielded positive findings for ethanol and for citalopram, a prescription antidepressant. It is likely that some of the ethanol was the result of postmortem production; however, due to limited tissue specimens, whether some of the ethanol was from ingestion or if it impaired the pilot could not be determined. It is unlikely that the pilot's use of citalopram resulted in impairment, but whether the pilot was impaired by the effects of depression could not be determined. Additionally, due to the extent of injury, autopsy was unable to determine if the pilot had any potentially impairing natural disease. Through a review of the pilot's FAA certified medical information, it was determined that the pilot was instrument rated. However, the pilot's logbook was not available, and investigators were not able to determine the pilots instrument currency.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot continued flight despite warnings against VFR in marginal conditions.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 18 docket documents
View NTSB final reportView NTSB docket

Docket documents18

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