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NTSB investigation record

CHI07FA176

Completed

Beech A36Tc· N3671S

NTSB Report
Date
June 22, 2007
Location
Cannon Falls, MN
Conditions
VMC
Record
Published September 2, 2021

Primary finding

Probable cause

The pilot's continued flight into instrument meteorological conditions, which resulted in spatial disorientaton and loss of control.

Investigator assessment

Analysis narrative

The private, non-instrument rated pilot departed in visual meteorological conditions (VMC) and requested visual flight rules (VFR) flight following to his destination. When he neared his destination, he contacted approach control and reported that his altitude was 2,500 feet above mean sea level (msl). Approach control informed the pilot that there were moderate to heavy rain showers over the destination airport. The pilot reported that he was experiencing "poor visibility" and was considering turning 180 degrees to "go back." Approach control informed the pilot that instrument meteorological conditions prevailed north of his position with moderate to heavy rain showers. The pilot reported, "We're, we're kinda in the soup at this point." The pilot reported that he was turning to the south and soon after the airplane was lost from radar contact. A witness reported that he heard an airplane and then saw the accident airplane descending through a cloud layer that was about 400 - 500 feet above the ground. The airplane was in about a 50-degree nose down attitude with the airplane's engine producing "cruise power." He reported that the airplane was flying at a high rate of speed for about four seconds until he heard the airplane impact the terrain. The observed weather in the area of the accident was reported as marginal VMC and instrument meteorological conditions. The inspection of the airplane revealed no preexisting anomalies.

Source record

Factual narrative

HISTORY OF FLIGHT On June 22, 2007, at 1417 central daylight time, a Beech A36TC Bonanza, N3671S, was destroyed when it departed from cruise flight and impacted terrain about 10 miles south of Cannon Falls, Minnesota. The 14 Code of Federal Regulations Part 91 personal flight departed DuPage Airport (DPA), West Chicago, Illinois, about 1230 and was en route to Air Lake Airport (LVN), Lakeville, Minnesota. The pilot, the sole occupant, was fatally injured. Marginal visual meteorological conditions (VMC) prevailed at LVN at the time of the accident. No flight plan was filed. The private pilot departed DPA in VMC. When the flight was near Wisconsin Dells, Wisconsin, the pilot requested visual flight rules (VFR) flight following, and a discrete transponder code was assigned to N3671S. The flight continued to receive VFR flight following while en route to LVN. At 1410:50, the pilot contacted Minneapolis Approach Control and reported that his altitude was 2,500 feet above mean sea level (msl). Approach control instructed the pilot that he could proceed direct to LVN, and informed him that there was moderate to heavy rain showers over LVN at the time. At 1413:08, the pilot reported to approach control that he was experiencing "poor visibility" and asked what the weather conditions were like ahead of him. He stated that he was considering turning 180 degrees to "go back." Approach control informed the pilot that instrument meteorological conditions (IMC) prevailed north of his position with moderate to heavy rain showers. At 1413:45, approach control asked the pilot if he was going to reverse course. The pilot replied, "Ah, affirmative, yea we're gonna make, we're gonna actually head, ah, due north." Approach control instructed the pilot to proceed to the northeast and maintain VFR. At 1414:53, approach control asked the pilot what was his current destination. The pilot responded, "We're deviating. I think we're going to go back over near Eau Claire, but, ah, we're going to see what the weather is like. We're, we're kinda in the soup at this point so I'm trying to get back, ah, to the east." At 1415:10, approach control informed the pilot that there was "some level one rain or some light rain showers" that were about seven miles ahead of his present position. At 1415:30, the pilot asked approach control, "What is the ah, ah, Lakeville weather? I was showing seven thousand and overcast on the system here. Is that still holding?" Approach control responded, "No, around [the] Minneapolis area we're overcast at twenty three hundred and twenty one hundred in the vicinity of all the other airports around here." At 1415:49, the pilot stated, "I'm going to head due south at this time, down to, ah, about two thousand and make it into Lakeville." Approach control responded, "November three six seven one sierra, roger, you can proceed south bound." At 1416:02, the pilot responded, "Seven one sierra, thanks (unintelligible)." The radar data indicated that the airplane's altitude was about 2,600 feet msl. There were no further radio transmissions from N3671S. After the last radio transmission, three radar returns indicated the airplane descended from 2,500 feet to 2,300 feet msl before it was lost from radar contact. A witness reported that he heard an airplane and then saw it descending through a cloud layer that was about 400 - 500 feet above the ground. He reported that the airplane was in about a 50-degree nose down attitude. He reported that he heard the airplane's engine producing "cruise power" and there were no indications of an engine malfunction such as sputtering. He reported that the airplane was flying at a high rate of speed. He saw the airplane traveling on an east to west heading for about four seconds when the airplane went behind a tree line. He reported that he heard the airplane impact the terrain. He reported that he called 911 and then went to the accident site to render assistance, if possible. PERSONNEL INFORMATION The pilot held a private pilot's certificate that was issued in August 1999. He was not instrument rated. The pilot's flight logbook that dated back to 2002 indicated that he had about 461 hours of total flight time with about 17 hours in make and model. He attended a Bonanza Initial Training Course in January 2007, and received 8 hours of simulator training in a BE-36 flight simulator. He flew 13.9 hours in the accident airplane between January 17 - 25, 2007. His logbook indicated that he had not flown since January 25, 2007. He had flown the accident airplane to DPA on May 10, 2007, for an avionics upgrade, but the flight was not entered into the pilot's logbook. There were no logbook entries that indicated he had received any actual or simulated instrument training other than the 8 hours of simulator training in January 2007. He held a third-class medical certificate that was issued on September 8, 2005. AIRCRAFT INFORMATION The airplane was single engine Beech A36TC Bonanza, serial number EA-95. The airplane seated six and had a maximum gross weight of 3,833 pounds. The engine was a 300-horsepower Continental TSIO-520-UB engine. The last annual inspection was conducted on November 8, 2007. The airplane had flown 37 hours since the last annual inspection and had a total time of 3,391 hours. According to insurance records, the pilot purchased the airplane on January 3, 2007. The airplane was delivered to an aircraft repair station at DPA on May 10, 2007, for an avionics upgrade. Among other things, the installed avionics included a Garmin GNS-430W GPS, a Garmin GMX-200 MultiFunction Display (MFD), and a Garmin GDL -69A XM/WX Data Link Receiver. The newly installed avionics system provided the pilot with the ability to obtain the following types of weather displays in the cockpit: Next-generation Radar (NEXRAD), Aviation Routine Weather Report (METARS), Terminal Area Forecasts (TAF's), temporary flight restrictions (TFR's), winds aloft, echo tops, precipitation type at the surface, lightning strikes, storm-cell data, Airman's Meteorological Information (AIRMET's), and Significant Meteorological Advisories (SIGMET's). During the ground tests after the avionics were installed, the Garmin 430W had a discrepancy noted against it, so it was replaced with a new Garmin 430W prior to the accident flight. METEOROLOGICAL INFORMATION The closest weather reporting facility to the accident site was Stanton Airfield (SYN), Stanton, Minnesota, located approximately 10 miles northwest of the accident site. The airport was equipped with an Automated Weather Observing System (AWOS-3), which issues observations every 20-minutes. The following conditions surrounding the time of the accident were reported: At 1355, the automated SYN weather observation was: wind from 140 degrees at 6 knots, visibility 5 miles in moderate rain, ceiling overcast at 1,300 feet, temperature 18 degrees Celsius (C), dew point temperature 17 degrees C, altimeter setting 30.04 inches of Mercury (Hg). Remarks: automated observation system, hourly precipitation 0.11 inches, lightning distant southwest. At 1415: wind from 130 degrees at 6 knots, visibility 4 miles in moderate rain, ceiling overcast at 1,300 feet, temperature 18 degrees C, dew point 17 degrees C, altimeter setting 30.04 inches of Hg. Remarks: automated observation system, hourly precipitation 0.04 inches. At 1435: wind from 150 degrees at 7 knots, visibility 5 miles in light rain, ceiling overcast at 1,300 feet, temperature 18 degrees C, dew point 17 degrees C, altimeter setting 30.03 inches of Hg. Remarks: automated observation system, hourly precipitation 0.05 inches. The planned destination was Airlake Airport (LVN), Minneapolis, located approximately 20 miles northwest of the accident site at an elevation of 960 feet msl. The airport was equipped with an AWOS-3 system an

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