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NTSB investigation record

CEN10FA044

Completed

Beech A36· N91TD

Date
November 8, 2009
Location
Spring Branch, TX
Conditions
IMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot's failure to maintain control of the airplane during cruise flight in instrument meteorological conditions. Contributing to this accident was the pilot’s lack of recent experience in flying in instrument meteorological conditions.

Investigator assessment

Analysis narrative

The pilot was on an instrument flight rules flight and was level at 9,000 feet mean sea level. Radar data showed that the airplane was flown in an area of heavy intensity rain echoes and was on a meandering course generally eastbound when it then began a shallow turn to the left and then began turning to the right. Radar data for the last 14 seconds of the flight showed that the airplane began a descent and was still turning to the right. Radio and radar contact was then lost. Two witnesses near the accident site reported hearing a loud noise and then seeing something very large with lots of smaller pieces falling out of the clouds. Separated portions of the airplane impacted terrain in a generally circular area about 500 feet in diameter, consistent with an in-flight breakup at a low altitude. A postaccident examination of the airplane showed no anomalies with the engine or other systems. A review of the pilot’s logbook showed that his last instrument flight experience was nearly 2 years prior to the accident. It also showed the pilot had recently purchased the airplane and had approximately 4 hours of flight time in it. A sedating antihistamine with impairing effects was found during a postmortem toxicological examination of tissue from the pilot, but no blood was available for analysis, so no determination could be made regarding how recently the medication might have been taken or whether the pilot could have been impaired by its use at the time of the accident.

Source record

Factual narrative

HISTORY OF FLIGHT On November 8, 2009, about 1130 central standard time, a Beech A36, N91TD, was lost from radar contact and impacted the ground approximately one mile northwest of Kestrel Airpark (1T7), Spring Branch, Texas. The pilot and the two passengers were fatally injured. The airplane was substantially damaged. The airplane was registered to Gold Cup Pawn Shop Inc., and operated by the private pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Instrument meteorological conditions (IMC) prevailed for the flight, which operated on a instrument flight rules flight plan. The flight originated from Kerrville Municipal Airport/Louis Schreiner Field (ERV), Kerrville, Texas, about 1110 and was en route to Pearland Regional Airport (LVJ), Pearland, Texas. According to transcripts and radar data provided by the Federal Aviation Administration (FAA), the airplane was in radar contact and the pilot was in voice communications with San Antonio air traffic control tower (ATCT) approach control. At 1118, the airplane was level at 5,000 feet mean sea level (msl) and with a clearance to climb to 9,000 feet msl. At 1121, the pilot acknowledged the San Antonio altimeter setting. At 1127, the airplane was level at 9,000 feet msl. At 1129, radar and radio contact with the airplane was lost. No distress call was received. A review of the radar data, obtained from the FAA, illustrated the flight was at about 9,000 feet msl on a meandering course generally eastbound. Radar data depicted the airplane began a shallow turn to the left at 1127:20 and then began turning to the right at 1128:44. A radar contact at 1129:32 showed the airplane in a right turn at 8,900 feet msl. The last radar contact at 1129:46 showed the airplane in a descending right turn at 6,400 feet msl. Two witnesses reported hearing a noise like an “airplane in a dive”, and then looked out their window and saw something very large with lots of smaller pieces falling out of the clouds. Several witnesses reported hearing the loud sounds of high engine rpms and then the sounds of impact. One witness heard an airplane flying “ridiculously low” over her house, and then heard a loud crashing noise. She ran out of her garage and saw debris flying in the air. PERSONNEL INFORMATION The pilot, age 60, held a private pilot certificate with an airplane single-engine land rating. An instrument airplane rating was added to that pilot certificate after the pilot passed a practical test on December 8, 2007. The pilot held a third-class airman medical certificate issued July 30, 2009, with limitations. One pilot logbook, marked logbook number 2, was available for examination. It covered the period beginning on November 2, 2003, until the last logbook entry on October 7, 2009. That logbook showed that the pilot had 885 hours of total pilot experience, including more than 500 hours in a Beech model J35, and a total of 84 hours in instrument flying conditions. The most recent entry in the logbook for instrument flight experience was on December 15, 2007. Based on witness information, the pilot flew about 4 hours in the accident airplane on November 6, 2009. A certified flight instructor (CFI) provided a statement that he gave 44 periods of flight instruction to the pilot during a 14 month period in 2005 and 2006 when the pilot was preparing for his instrument airplane rating. The CFI perceived the pilot had developed an over reliance on the autopilot, was reluctant to read the flight manual, and not normally use a cockpit checklist. Consequently, the pilot would forget to complete required tasks and was easily distracted, sometimes at critical points in the flight. The CFI’s opinion was that the pilot had lost, or had never developed, basic instrument skills. In addition, the CFI thought that the pilot had good basic visual flight rules (VFR) flying skills and was generally cautious in his flying, but at times, was over confident in his flying ability. . A second CFI said he had given about 34 hours of flight instruction to the pilot during the three month period before the pilot successfully passed his instrument check ride in December 2007. The CFI said the pilot was flying an older V tail Bonanza which he flew very well and the pilot was proficient in all operations of the aircraft. The second CFI reported that he had flown N91TD with the pilot only once, when he gave a single 1.2 hour period of flight instruction on November 6, 2009. The CFI recalled the pilot flew the new airplane well, but struggled with the different autopilot and avionics in the new airplane. The CFI had told the pilot that he did not believe he was ready to fly the airplane in IMC until the pilot had gained more experience and received more instruction in the new airplane. AIRCRAFT INFORMATION The six-seat, low-wing, retractable-gear airplane, serial number E-2624, was manufactured in 1991. It was powered by a Continental IO-550-B(6) 300 horsepower engine and equipped with a Hartzell 3-blade, constant speed, aluminum alloy propeller. A review of the maintenance logbook records showed an annual inspection was completed on November 3, 2008, at an airframe total time of 2744.8 hours, an engine total time of 1705.0 hours, and engine time since major overhaul of 233.7 hours. The last entry in the aircraft maintenance logbook showed a “pre buy” inspection was completed on November 4, 2009, at an airframe total time of 3065.4 hours. Damage sustained to the Hobbs hour-meter during the accident precluded obtaining the airplane’s current reading. The airplane was equipped with a Bendix/King KFC-150 autopilot with KAS-297B altitude preselect, a Garmin MX20 multifunction display, and a Garmin GNS 430W navigation and communications unit. It was also equipped with a Ryan TCAD ATS-8000 collision avoidance system, and a WX-1000 stormscope. FAA aircraft registry records show that the airplane was registered to the owner on October 22, 2009. METEOROLOGICAL INFORMATION The closest weather reporting station to the accident site was from San Antonio International Airport (KSAT), San Antonio, Texas, located approximately 18 miles south of the accident site at an elevation of 809 feet msl. The airport was equipped with an Automated Surface Observation System (ASOS) and was augmented by NWS certified weather observers. A thunderstorm with heavy rain had been reported at San Antonio between 1008 and 1039 and had moved northwestward. Rain continued at the time of the accident, when the following conditions were reported: San Antonio special weather observation at 1137, wind from 120 degrees at 4 knots, visibility 2 miles, runway 12R visual range 3,000 feet variable 6,000 feet, heavy rain and mist, ceiling broken at 300 feet, broken at 1,600 feet, and overcast at 2,200 feet, temperature 19 degrees C, dew point temperature 18 degrees C, and an altimeter setting of 30.05 inches of mercury. Remarks: automated observation system, ceiling 200 variable 800 feet, hourly precipitation 0.33 inches. The closest upper air sounding or rawinsonde observation (RAOB) was from the NWS Corpus Christi (KCRP), Texas, location approximately 130 miles southeast of the accident site at an elevation of 43 feet msl. The 0600 sounding depicted a surface based temperature inversion, where temperature increased with height to 254 feet above ground level (agl) before decreasing. The sounding was also characterized as being a moist low-level environment from the surface to 16,000 feet with a lifted condensation level (LCL) at 338 feet agl, a convective condensation level (CCL) at 3,324 feet agl, and a level of free convection (LFC) at 4,473 feet agl. The precipitable water content was 1.65 inches. The expected top of convective clouds was estimated by the equilibrium level (EL) to be 30,058 feet, with the tropopause height identified at 55,664 feet. The freezing level was identified

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