Pilot Debrief

BEECH D17S near Santa Fe, NM — 2018-05-25

Final reportCEN18FA192
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Date
2018-05-25
Location
Santa Fe, NM, USA
Aircraft
BEECH D17S
Registration
N79091
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Cruise

Probable cause

The pilot's failure to maintain clearance from terrain for reasons that could not be determined based on the available information.

NTSB narrative

The commercial pilot was conducting a cross-country flight in day visual meteorological conditions. Automatic dependent surveillance-broadcast (ADS-B) track data revealed that most of the flight was flown at a cruise altitude of 10,500 ft mean sea level (msl) on a direct course to the planned destination. About 23 minutes before the accident, the airplane began shallow turns to the right and left of a direct course to the destination, consistent with the pilot making manual course corrections as the airplane continued toward the airport. Similarly, the airplane's altitude began to fluctuate ±100 feet from the target cruise altitude of 10,500 ft msl. About 2.5 minutes before the accident, the airplane entered a descent from 10,500 ft msl. During the final 2 minutes of the flight, the airplane had an average descent rate of 1,375 ft per minute and a ground speed between 99 knots and 121 knots. The final ADS-B return was about 385 ft east-northeast of the accident site at 7,025 ft msl (near ground level), and the ground speed was about 106 knots. At no point during the flight did the pilot declare an emergency with air traffic control or report having any problems. There were no witnesses to the accident. Examination of the airframe and engine revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. The airplane's landing gear and flaps were retracted. The fuel tanks ruptured during impact; however, fuel was observed in fuel lines, the engine-driven fuel pump, and the carburetor. The propeller exhibited damage consistent with the engine operating at the time of impact. Autopsy and toxicology of the pilot revealed no evidence of physiological impairment or incapacitation. The reason for the airplane's descent and impact with terrain could not be determined based on the available information.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have declared an emergency when altitude began to fluctuate.

NTSB coding

Evidence available

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

Docket documents21

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