Pilot Debrief

BEECH B36 near Panoche, CA — 2012-03-15

Final reportWPR12FA139
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Date
2012-03-15
Location
Panoche, CA, USA
Airport
CVH
Aircraft
BEECH B36
Registration
N364AB
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Descent

Probable cause

The pilot’s lack of situational awareness regarding the surrounding terrain while descending during dark night conditions, which resulted in controlled flight into terrain.

NTSB narrative

The pilot was delivering the single engine airplane from England to the west coast of the United States. According to his resume, he had piloted 196 Atlantic crossings in general aviation airplanes. The trip began about 1 week before the accident. The flights from England to Maine, with a pilot-rated passenger on board, consisted of 6 legs, with a total flight time of about 27 hours over a period of about 96 hours. The passenger and pilot separated in Bangor, Maine, and the pilot continued to Kentucky that same day, with an additional 2 legs and 6 hours flight time. He spent a total of 13 hours on the ground in Kentucky before departing early in the morning on the day of the accident. The first leg was 5 hours followed by a fuel stop. The next leg was 3 hours 20 minutes, and another fuel stop was made. The pilot then departed on the accident leg to his destination in California. The pilot flew the over 4-hour accident leg under visual flight rules using air traffic control flight following services. He flew directly between waypoints instead of on established airways. The airplane was equipped with a panel-mounted GPS unit with altitude information capability, and the pilot's iPad was equipped with current flight planning and guidance software, and electronic navigation charts. The pilot had access to sufficient information in flight to remain clear of terrain, but the investigation was unable to determine whether the pilot accessed that information during any part of that flight leg. When the airplane was about 65 miles from its destination, the pilot began a steady descent from his cruise altitude of 12,500 feet, which he had flown without supplemental oxygen. The destination elevation was 230 feet. Due to coverage limitations, radar contact with the airplane was lost when it was descending through 5,100 feet. At this point, the airplane was 46 miles from its destination, and the controller cancelled the flight-following services. There were no further communications from the pilot; up to this point, he had acknowledged all transmissions from ATC. Twelve miles after flight-following services were cancelled, the airplane impacted a hillside at an elevation of about 1,960 feet. Ground scar and wreckage information indicated that the airplane impacted in a wings-level attitude on a near-horizontal flight path. The airplane was highly fragmented and damaged by postimpact fire. Evidence was consistent with the landing gear and flaps retracted. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Darkness prevailed at the time of the accident, and AIRMETs for mountain obscuration were current for the time and location of the accident. Satellite and weather radar data suggested the presence of instrument meteorological conditions along parts of the airplane's route, but the investigation was unable to determine whether the pilot encountered or entered instrument meteorological conditions during the descent. Extrapolation of radar-derived speed and descent rate data indicated that the airplane descended steadily on track from cruise to the impact point. The pilot's autopsy indicated that the cause of death was multiple blunt trauma injuries, with no adverse pre-existing conditions. The effects of possible fatigue or hypoxia on the pilot's performance could not be determined.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have filed a flight plan and obtained weather briefings before departure.

NTSB coding

Evidence available

  • Video
  • ADS-B / radar
  • 26 docket documents
View NTSB final reportView NTSB docket

Docket documents26

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