N364AB

Substantial
Fatal

BEECH B36S/N: EA-519

Accident Details

Date
Thursday, March 15, 2012
NTSB Number
WPR12FA139
Location
Panoche, CA
Event ID
20120317X91318
Coordinates
36.528057, -120.843055
Aircraft Damage
Substantial
Highest Injury
Fatal
Fatalities
1
Serious Injuries
0
Minor Injuries
0
Uninjured
0
Total Aboard
1

Probable Cause and Findings

The pilot’s lack of situational awareness regarding the surrounding terrain while descending during dark night conditions, which resulted in controlled flight into terrain.

Aircraft Information

Registration
N364AB
Make
BEECH
Serial Number
EA-519
Engine Type
Reciprocating
Year Built
1991
Model / ICAO
B36BE36
Aircraft Type
Fixed Wing Single Engine
No. of Engines
1

Registered Owner (Historical)

Name
JIM LAFFERTY AIRCRAFT SALES INC
Address
1250 AVIATION AVE STE 165
Status
Deregistered
City
SAN JOSE
State / Zip Code
CA 95110-1134
Country
United States

Analysis

HISTORY OF FLIGHT On March 14, 2012, about 1955 Pacific daylight time (PDT), a Beech B36TC, N364AB, was substantially damaged when it impacted terrain in the Diablo Mountain range near Panoche, California, during a delivery flight from Gloucester, England, to San Jose, California. The airplane was recently purchased and operated by Lafferty Aircraft Sales (LAS), and was operated by American King Air Services (AKAS). The pilot sustained fatal injuries. The accident leg of the flight was conducted under the provisions of 14 Code of Federal Regulations Part 91, and in accordance with visual flight rules (VFR). Darkness and possible instrument meteorological conditions prevailed, and no Federal Aviation Administration (FAA) flight plan was filed for the flight.

According to the pilot-rated passenger who flew with him for a portion of the trip, the pilot took a commercial flight from South Carolina to Florida on March 7, 2012, and the two of them then flew commercially to London, England, that evening. They arrived in London on March 8, and began the delivery flight the next day. They landed in Bangor, Maine, on March 13, where the passenger separated and returned to Florida via commercial airline service. The pilot continued with the delivery flight, and made an overnight stop in Kentucky that evening. The pilot departed Kentucky about 0900 local time on March 14, made one fuel stop in Oklahoma, and a second in Arizona. During the Arizona fuel stop, the pilot informed his wife that his planned overnight stop was at Hollister Municipal Airport (CVH), Hollister, California, and that the route for the last segment of that flight was direct from the Palmdale very high frequency omnirange facility (PMD VOR) to CVH.

By the morning of March 15, neither the wife nor the pilot's business partner had heard from the pilot, and they began attempts to contact him. The FAA issued an Alert Notice (ALNOT) for the missing airplane later that morning. About 1200 PDT on March 17, the wreckage was found on a hillside, located on a ground track between PMD and CVH. The wreckage was located on a steep slope, was highly fragmented, and was damaged or consumed by fire. All major airplane components, or elements from them, were identified at the accident site. The wreckage was recovered to a secure facility for additional examination.

The passenger stated that they did not experience any mechanical anomalies during his trans-Atlantic portion of the trip. While at the fuel stop in Arizona, the pilot told his wife that the airplane was performing "perfectly."

PERSONNEL INFORMATION

The pilot was the president of AKAS, located in South Carolina. According to its website, one service provided by AKAS was the transport/delivery of airplanes over long distances. The pilot was transporting the airplane for LAS of San Jose, California.

Records provided by the FAA and LAS indicated that the pilot held multiple certificates and ratings, including an Airline Transport Pilot certificate. The 78-year-old pilot reported a total flight experience of about 13,400 hours, including about 300 hours in Beech 35/36 airplanes. His most recent FAA second-class medical certificate was issued in October 2011. The pilot's resume reported that he had 196 Atlantic crossings in general aviation aircraft.

According to persons knowledgeable about the pilot's flying habits, whenever possible, although he was instrument rated and current, the pilot preferred to fly under VFR, and via direct routes using GPS. Witness and tracking data from the flight indicated that the pilot's behavior and actions were consistent with his reported preferences.

Details regarding the pilot's wake/sleep cycles and quality of sleep during the trip were not available.

In September 2007, based on a telephone call from an unidentified woman, the FAA began an investigation into the pilot's fitness to hold a second-class medical certificate. The caller claimed that the pilot had significant vision and hearing deficiencies. In spring 2007, the FAA determined that the pilot remained qualified to hold that certificate, and the available evidence indicated that the complainant was the pilot's ex-wife.

AIRCRAFT INFORMATION

The airplane was manufactured in 1991, and was equipped with a Continental Motors TSIO-520 series engine. The most recent annual inspection was completed in England on March 9, 2012. The maintenance records indicated that at the time of that inspection, the airframe, engine, and propeller each had a total time in service of 1,302 hours. The records also indicated that about 20 discrepancies that were noted by the inspecting technicians were dispositioned as "owner requests no action," and therefore no corrective actions for those items were accomplished.

The airplane was equipped, approved, and current for instrument flight rules (IFR) operations. In addition to the normal complement of avionics, the airplane was equipped with an autopilot and a King KLN-90B IFR certified GPS navigation system.

METEOROLOGICAL INFORMATION

On the day of the accident, accident locale sunset occurred at 1913, and local civil twilight ended at 1938. The moon did not rise until 0144 the next morning.

AIRMETs for icing, IFR conditions, and mountain obscuration were current for the accident locale and flight altitudes. The investigation was unable to determine whether the pilot was aware of those AIRMETs.

METARs from surrounding airports about the time of the accident were as follows:

CVH (leg destination; ~34 nm northwest of accident, elevation 230 ft)

1945 PDT Wind 290 degrees at 7 knots, visibility 10 miles, few clouds at 1,400 ft agl, overcast at 3,000 ft agl, temperature 14 degrees C, dew point 12 degrees C

2005 PDT Wind 300 degrees at 5 knots, visibility 10 miles, overcast at 3,000 ft agl, temperature 14 degrees C, dew point 12 degrees C

SJC (San Jose, ultimate destination; ~72 nm northwest of accident, elevation 62 ft)

1953 PDT Wind 100 degrees at 5 knots, visibility 10 miles, light rain, few clouds at 1,500 ft agl, scattered clouds at 3,000 ft agl, overcast at 6,500 ft agl, temperature 14 degrees C, dew point 12 degrees C

SNS (Salinas, ~38 nm west northwest of accident, elevation 85 ft)

1953 PDT Wind 340 degrees at 6 knots, visibility 10 miles, light rain, overcast at 6,500 ft agl, temperature 16 degrees C, dew point 12 degrees C

NLC (LeMoore, ~45 east southeast nm west northwest of accident, elevation 232 ft)

1956 PDT Wind 350 degrees at 8 knots, visibility 10 miles, scattered clouds at 6,500 ft agl, overcast at 15,000 ft agl , temperature 18 degrees C, dew point 8 degrees C

Rawinsonde data (information derived from an instrument package ascending through the atmosphere) identified a saturated or near-saturated environment between about 3,300 and 8,200 feet mean sea level (msl). A cross-section of that data identified an extensive area of relative humidity values greater than 94 percent between near-surface altitudes and approximately 4,300 feet msl. Satellite imagery indicated that cloudy conditions dominated much of the accident region, but a layer of high clouds prevented determination of whether clouds were present along the airplane's flight path or at the flight elevations near the accident site. Doppler weather radar imagery did not indicate significant meteorological targets above the accident location between altitudes of 3,100 and 9,100 feet msl.AIDS TO NAVIGATION

According to the pilot's business partner, the pilot wanted to ensure that the database in the KLN 90B GPS unit was updated for the United States before he began the flight, and the partner understood that that update had been accomplished. According to a representative of the manufacturer of the KLN 90B, the device includes altitude features such as Minimum Safe Altitudes, Minimum En route Altitudes and altitude alerting.

The pilot also had a personal iPad with the "ForeFlight" program installed. The pilot-rated passenger who accompanied him from England to the US reported that the pilot used the iPad for that portion of the trip. The iPad was recovered from the wreckage and sent to the NTSB Recorders laboratory for download. The iPad/Foreflight does not store track data. The last map viewed in the ForeFlight program was that of the accident route leg, overlaid on IFR (instrument flight rules) low altitude en route charts. The accident leg route on the device was depicted as a straight line between the PMD VOR and CVH, the destination airport.

Reconstruction of the flight route from England to the accident location, using commercial tracking vendor data and air traffic control radar data, revealed that the pilot primarily flew direct legs between origin and destination airports, as opposed to routes that used established airways and ground-based navigation facilities.

The iPad/Foreflight examination results indicated that the pilot had the information necessary to enable him to determine the minimum safe altitudes for his route of flight and current location. A review of the applicable VFR Sectional chart revealed that the charted Maximum Elevation Figure (MEF) was 5,600 feet msl in the vicinity of the accident location. MEF values provide pilots with a ready means to ensure terrain clearance, and they range between 100 and 300 feet above the highest obstruction within a given quadrangle. A review of the applicable En route Low Altitude IFR chart revealed that the applicable OROCA (Off Route Obstruction Clearance Altitude) was 7,600 feet msl. CVH elevation was 230 feet msl. The airplane impacted terrain at an elevation of 1,960 feet msl.

COMMUNICATIONS

Flight Services

Once in the US, the pilot did not file any flight plans, and did not obtain any official preflight weather briefings through Lockheed Martin Flight Services (LMFS), either telephonically or via the Internet. No records of any other pilot attempts to obtain weather information from other sources were located.

The on...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# WPR12FA139