Pilot Debrief

HAWKER BEECHCRAFT G58 near Alpharetta, GA — 2022-10-31

Final reportERA23FA047
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Date
2022-10-31
Location
Alpharetta, GA, USA
Airport
PDK
Aircraft
HAWKER BEECHCRAFT G58
Registration
N495AU
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Approach

Probable cause

The pilot’s loss of aircraft control for unknown reasons.

NTSB narrative

The 76-year-old pilot was attempting an instrument approach in instrument meteorological conditions. He was cleared for the approach and air traffic control (ATC) instructed the pilot to maintain an altitude of 3,000 ft mean sea level (msl) until established on the approach. The pilot did not read back the altitude assignment in the clearance and a controller had to re-state the clearance. The pilot acknowledged with the airplane’s call sign only. The airplane was then observed to climb and descend above and below the assigned altitude, which triggered a Minimum Safe Altitude Warning (MSAW) alert to ATC. A controller immediately informed the pilot, who responded that he was climbing and “going around.” The controller instructed the pilot to climb to the assigned altitude of 3,000 ft msl, to turn to a specific heading, and to keep his wings level. The pilot repeated the instructions. The airplane then entered a climbing right turn to 3,200 ft msl, before it made a descending left turn. The controller continued to receive low altitude alerts and made numerous attempts to contact the pilot, but there was no response. The airplane continued to descend until it was no longer observed on radar. A witness heard the airplane’s engines operating at a high rpm as it descended wings-level from the cloud cover. He thought that the pilot would have had time to realize his proximity to the ground, but saw that the pilot never reacted and the airplane flew into the ground. Postaccident examination of the airplane revealed it sustained extensive impact damage consistent with impacting the ground at a high rate of speed. No evidence of any preimpact mechanical malfunctions or failures were identified, to the extent possible, that would have precluded normal operation. The pilot’s medical history, including chronic lymphocytic leukemia (CLL), prostate cancer, aortic valvular stenosis, hypertension, and mini stroke, conveyed increased risk of medical impairment. The pilot’s family also stated that he was not feeling well in the months leading up to the accident. However, the extent of the pilot’s injuries prevented any forensic determination regarding possible medical impairment during the flight. Additionally, ethanol was detected at a low level in the only available postmortem specimen. Some or all of the small amount of detected ethanol may have been from postmortem production. It is unlikely that ethanol effects contributed to the accident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot did not read back altitude assignment, leading to altitude loss.

NTSB coding

Evidence available

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

Docket documents15

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