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NTSB investigation record

CEN14FA249

Completed

Raytheon aircraft company G36· N536G

Date
May 23, 2014
Location
Silver City, NM
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The airplane’s encounter with a strong tailwind and/or windshear, which resulted in an inadvertent stall. Contributing to the accident was the pilot’s continuation of the unstable approach, long landing, and delayed decision to conduct a go-around.

Investigator assessment

Analysis narrative

The airplane was returning from a local flight and the pilot flew a tight downwind leg for landing on runway 35, possibly due to a direct crosswind in excess of 20 knots. During the base turn, the airplane overshot the final course, and the pilot used at least 60 degrees of bank to correct the airplane back on course and over the runway. The airplane then bounced and touched down at least 20 knots above the manufacturer's published approach speed with about 1,810 ft remaining on the runway. The airplane's airspeed began to rapidly decrease, but then several seconds later, the airplane's airspeed increased as the pilot rejected the landing. The airplane did not gain significant altitude or airspeed then began a slight right turn. The airplane's roll rate then sharply increased, and the airplane quickly descended, consistent with a stall, before colliding with a transmission wire and terrain. Examination of the airframe and engine did not reveal any preimpact anomalies that would have precluded normal operation. Strong, variable, gusty wind, with an environment conductive to the formation of dry microbursts, was present at the airport at the time of the accident. Several lightning strikes were recorded in the vicinity of the accident site around the time of the accident. It is unknown if the presence of lightning or wind impacted the pilot's inflight decision-making in the pattern, on approach, or during the attempted go-around. The circumstances of the accident are consistent with an in-flight encounter with a strong tailwind and/or windshear during climbout after the rejected landing. An autopsy conducted on the pilot identified significant stenosis of a distal coronary artery without any other evidence of cardiac distress; however, if there was an associated medical event, the condition would likely result in sudden incapacitation, which is not consistent with the airplane's coordinated flight profile.

Source record

Factual narrative

The Whiskey Creek Airport (94E) is a public airport located at measured altitude of 6,126 feet mean sea level. It has one runway 17/35, 5,400 feet by 50 feet, of asphalt construction in good condition. Pilot Operating Handbook Beechcraft's Model G36 Bonanza Pilot's Operating Handbook (POH), revised July 2014, listed the maximum demonstrated crosswind limit as 17 knots. The Normal Procedures section lists the balked landing checklist: 1. Throttle and Propeller … Full Forward 2. Airspeed …80 KTS (until clear of obstacles, then trim to 110 KTS) 3. Flaps … UP 4. Landing Gear … RETRACT 5. Cowl Flaps … OPEN Published landing performance data for the airplane is predicated on a threshold speed between 78-81 knots depending on the airplane's weight. Published performance data does not exist for landings in excess of the published approach speeds or in excess of 10 knots of tailwind. Using a gross weight of 3,400 pounds, a direct crosswind of 20 knots, 70° F, and an approach speed of 80 knots, engineers from Textron Aviation estimated the required landing distance at 1,720 feet. The POH provided a chart of stall speeds with idle power. The chart was run for the airplane's final configuration of flaps up and airplane gross weights between 2,800-3,600 pounds. The stall speed at 30° of bank would be between 66-72 knots. Garmin Oregon 450t The Garmin Oregon 450t is a battery operated hand-portable GPS receiver with a 12 channel wide area augmentation system (WAAS). The unit contains an electronic compass and a barometric pressure sensor for recording pressure-based altitude information. Published GPS position location accuracy is less than 33 feet horizontal under normal conditions, and 10-16 feet with differential global positioning system (DGPS) active. Although the device was thermally damaged, the airplane's last flight track was extracted. For the accident flight, the device was powered on at 1401 and recorded the airplane's takeoff time of 1536 as the flight departed on runway 17. The airplane turned to the north and flew about 13 miles north in an area between Black Peak and New Mexico Highway 15. The airplane then returned back to 94E and entered a left base turn for runway 35. Starting at 1551, the GPS update rate began to vary and there were two episodes of where the GPS receiver momentarily lost satellite lock and continued to record position information based on projected data. About 1552:15, as the airplane turned left towards the runway, the receiver lost satellite lock and the airplane's position returned at 1552:42 as the airplane was over the runway. At that time, the airplane was about 770 feet down the runway and 175 feet above ground level. At 1552:53, the airplane touched down with a groundspeed of 120 knots, skipped, and touched down 3 seconds later at 100 knots groundspeed with about 1,810 feet remaining on the runway. The airplane slowed to 87 knots and with 1,060 feet remaining on the runway the airplane's groundspeed began to increase. The airplane lifted off from the runway, flew to the north, and began a slight climb. At 1553:12, the airplane began to turn right at a rate of about 3-4° per second. About 1553:26, the receiver again lost satellite lock and regained the airplane's position about 30 seconds later at the accident site. The final portion of the accident sequence was not captured by the device. iPhone An Apple iPhone was located in the airplane's wreckage and shipped to the NTSB laboratories for download. Data extracted from the iPhone showed that none of the video files were date/time stamped on the day of the accident. Thirty eight of the image files were date/time stamped on the day of the accident. Most of these files depicted persons and aircraft on the ground. Ten of these files corresponded with previews or full resolution images of the view off the right wing from inside an aircraft in-flight. The file containing the most recent image was taken at 15:46:35 MDT. There was no data which could aid in reconstructing in accident sequence. Secure Digital (SD) Card An SD card was found in a thermally damaged camera in the airplane's wreckage. The SD card was extracted from the camera and shipped to the NTSB laboratories for download. Data extracted from the SD card found that two of the video files were date/time stamped on the day of the accident. Twenty of the image files were date/time stamped on the day of the accident. All of the image files corresponded with external views of an airplane on the ground or in-flight views looking forward or off the right wing. The most recent image was time stamped 1546 MDT. The two video files depicted in-flight views looking forward or off the right wing from an airplane in level flight. There was no data which could aid in reconstructing in accident sequence. An autopsy was authorized and conducted on the pilot by the New Mexico Office of the Medical Investigator. The cause of death was the result of multiple blunt trauma and the manner of death was ruled an accident. The autopsy identified 80% stenosis of the distal third left anterior descending coronary artery. All other arteries were free of stenosis. Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. Testing detected the presence of oxymetazonline which is a decongestant used in the treatment of nasal congestion. The airplane impacted desert terrain near several trailer homes, about 0.8 miles northeast of runway 35's departure end. The airplane's first impact point was a transmission wire located west of the accident site about 25 feet above the ground. Forty feet east of the transmission wire was a ground crater which contained the airplane's propeller. The debris path was roughly cone shaped, was aligned on a 77° magnetic heading, and was about 140 feet long and 70 feet at its widest area. A postimpact fire ensued which consumed a majority of the airplane. The main wreckage contained remnants of the cabin, fuselage, wings, and empennage. The wreckage came to rest facing a 228° heading. Both ailerons were partially consumed by the postimpact fire and remnants remained attached to their respective wing. The left aileron trim actuator extension was measured and found to be about 1.75 inches, which corresponded to about 7° trim tab trailing edge down. Aileron control continuity was established from the flight controls to each wing bell crank. Aileron trim control cable continuity was confirmed from the cockpit to the aileron trim actuator. The flaps actuator indicated the flaps were up. The left and right elevator flight control surfaces were partially consumed by the postimpact fire. Remnants of the elevators remained attached to their respective horizontal stabilizer. The left and right elevator trim actuator extensions were measured and found to be 1.625 inches, which corresponded between 10-15° trim tab trailing edge down, airplane nose up. Elevator control continuity was confirmed from the cockpit to the elevator surfaces. The elevator trim control cables were confirmed from the cockpit to the trim actuators. The rudder was partially consumed by the postimpact fire and remnants remained attached to the vertical stabilizer. Rudder control continuity was established from the cockpit to the rudder bell crank. The gear handle was found in the down position. The fuel selector was found selecting the right main tank. No preimpact anomalies were detected with the airframe. The engine was impacted damaged and found separated from the airframe. Both magnetos were actuated by hand and found to produce a spark at each terminal. The fuel manifold valve screen was clear of debris and all fuel nozzles were found clear of blockages. The throttle body and fuel metering unit's fuel screen contained a small amount of fibrous material but was largely unobstructed. The crankshaft was able to be

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