Pilot Debrief

BEECH A35 near Gustavus, AK — 2024-07-20

Final reportANC24LA069
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Date
2024-07-20
Location
Gustavus, AK, USA
Aircraft
BEECH A35
Registration
N410B
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Cruise

Probable cause

The pilot’s decision to continue the visual flight rules flight into instrument meteorological conditions, which resulted in controlled flight into terrain.

Contributing factors

Findings Environmental issues Below VFR minima - Contributed to outcome Environmental issues Obscuration - Contributed to outcome Environmental issues Low visibility - Contributed to outcome Personnel issues Decision making/judgment - Pilot Personnel issues Identification/recognition - Pilot

NTSB narrative

The accident airplane departed Juneau on a visual-flight-rules flight; according to ADS-B data, the flight initially headed northwest for about 72 miles. The airplane’s track then changed direction to a southwesterly heading and began flying through the mountainous terrain of Glacier Bay National Park for an additional 30 miles. The airplane’s flight track continued along a westerly heading of 245°, at an altitude of 10,875 ft above mean sea level (msl) and with a groundspeed of 141 kts, consistent with straight and level flight, before it abruptly stopped on the eastern side of East Crillon mountain. The elevation of the terrain above the last data point is about 11,220 ft msl. A preliminary NTSB weather study indicated cloud bases as low as 2,200 ft msl and tops no lower than 12,000 ft msl in the accident region, with surface visibilities less than 0.25 statute miles. The High-Resolution Rapid Refresh (HRRR) model suggested the presence of clouds from 3,000 ft msl to 12,500 ft msl in the accident region. The National Weather Service (NWS) had issued an Airmen’s Meteorological Information (AIRMET) for mountain obscuration in the accident region. An aerial search of the accident site and the surrounding area revealed portions of highly fragmented airplane wreckage on the eastern side of East Crillon mountain about 6,260 ft msl. The portions of wreckage were found more than 4,500 ft below the suspected initial impact site, and spread out over an area of rough, steep, and crevasse-covered glaciated terrain. Portions of the fragmented wreckage were subsequently identified as belonging to the accident airplane by comparing photos of the airplane’s distinctive paint scheme with photos of the wreckage. Due to dangerous conditions present at the accident site, the wreckage could not be recovered.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot did not obtain a preflight weather briefing from an official source.

NTSB coding

Evidence available

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

Docket documents9

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