N1160T

Substantial
Fatal

BEECH V35BS/N: D-9928

Accident Details

Date
Tuesday, August 19, 2014
NTSB Number
WPR14FA349
Location
Novato, CA
Event ID
20140819X12142
Coordinates
38.173889, -122.704719
Aircraft Damage
Substantial
Highest Injury
Fatal
Fatalities
1
Serious Injuries
0
Minor Injuries
0
Uninjured
0
Total Aboard
1

Probable Cause and Findings

The instrument-rated pilot's decision to conduct a visual approach to the airport in night, instrument meteorological conditions, which resulted in controlled flight into terrain. Contributing to the accident was the pilot's loss of situational awareness, the controller's failure to provide clear and concise instructions to the pilot following his declaration of an emergency, and the controller's failure to provide adequate information to the pilot regarding the airplane's proximity to terrain.

Aircraft Information

Registration
N1160T
Make
BEECH
Serial Number
D-9928
Engine Type
Reciprocating
Year Built
1976
Model / ICAO
V35BBE35
Aircraft Type
Fixed Wing Single Engine
No. of Engines
1

Registered Owner (Historical)

Name
MADGE ROBERT J
Address
820 BAY HARBOUR DR
Status
Deregistered
City
REDWOOD CITY
State / Zip Code
CA 94065-1765
Country
United States

Analysis

On August 18, 2014, at about 2130 Pacific daylight time, a Beech B35, N1160T, collided with terrain while maneuvering near Novato, California. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. The private pilot was fatally injured and the airplane was substantially damaged. Visual and instrument meteorological and dark night conditions prevailed in the area at the time of the accident. An instrument flight rules (IFR) flight plan was filed for the flight. The cross-country flight originated from Brookings Airport (BOK), Brookings, Oregon at 1920 with a destination of San Carlos Airport (SQL), San Carlos, California.According to air traffic control (ATC) communications, the pilot was in contact with a SeattleRoute Traffic Control Center (ARTCC) controller and was transferred to an Oakland ARTCC controller during the southbound flight. Soon after being transferred, the pilot reported a loss of engine power. The controller initially gave the pilot vectors to Sonoma County Airport (STS), Santa Rosa, California about 27 miles to the north of (behind) the pilot's position, and followed up by issuing vectors to Gnoss Field (DVO) Novato, about 19 miles to the east of the airplane's position. After that discussion, during which the airplane had turned west, north, and then later east, the pilot reported that the engine power had returned. That statement was about 5 minutes after the pilot's initial notification to ATC of an engine problem. The pilot continued eastbound, and shortly thereafter there was a simultaneous loss of radar and radio contact, when the airplane was about 8 miles west of DVO.

Review of radar data provided by the Federal Aviation Administration revealed a primary target, consistent with the accident airplane, was traveling on a southbound heading at 7,200 feet indicated altitude before descending over the next 7 minutes to about 6,000 feet mean sea level (msl). The radar then depicted a right turn to a northerly heading, while continuing to descend to about 5,000 feet. The data further depicted the target enter a left 270 degree left turn followed by an easterly heading while descending down to below 2,000 feet. The target then ascended to about 3,000 feet and made several left and right turns before heading east towards the DVO area. The last 10 radar targets depicted an easterly heading while descending to about 1,000 feet. The last radar target was about 1/3 mile from the accident location.

The airplane was the subject of an Alert Notification, and the wreckage was located early the next morning, near the location of the last radar contact at an elevation of about 700 feet. About 32 acres of land was burned during the postimpact fire.

A witness located about 2 1/2 miles south-southwest of the accident site described an airplane flying at a low altitude over his house about the time of the accident. He stated the sound of the engine was loud as it passed by overhead, drowning out the sound of the TV that he was watching. The witness's brother that lives 1 1/2 miles further west of the first witnesses house, also stated that an airplane flew over his house about the time of the accident and seemed to be at a low altitude and the sound of the engine was loud. He concluded that there was heavy fog at the time and that didn't clear up until the following day.

PERSONNEL INFORMATION

The pilot, age 51, held a private pilot certificate with an airplane single-engine land, and instrument rating. The most recent third-class FAA medical certificate was issued in June 2008, with no limitations. The pilot reported on that medical certificate application that he had accumulated 650 total flight hours and 50 hours in the last 6 months. The pilot logbooks were not obtained during the investigation.

AIRCRAFT INFORMATION

The four-seat, low-wing, Beechcraft V35B Bonanza, serial number (S/N) D-9928, was manufactured in 1976. It was powered by a Continental IO-520-BB (10) engine, serial number 285974, rated at 285 horse power and equipped with a McCauley model 3A32C76-SMR variable pitch propeller. Review of the maintenance logbook records showed an annual inspection was completed May 23, 2014, at a recorded tachometer reading of 2,707 hours, airframe total time of 2,707 hours and engine time since major overhaul of 852 hours. Due to post-accident thermal damage, the current tachometer and Hobbs hour-meter readings were not obtained.

On August 17, 2014, the airplane was refueled with 52 gallons of 100LL fuel at the Southwest Oregon Regional Airport, North Bend, Oregon.

METEOROLOGICAL INFORMATION

The closest weather reporting station to the accident site was located at DVO, which was located 9 miles east of the accident site, at an elevation of 2 feet msl. At 2115, fifteen minutes prior to the accident, the station disseminated an automated observation report; wind calm, visibility 10 statute miles, sky clear, temperature 15° C, dew point 13° C, altimeter 29.83 inches of mercury.

At DVO, weather conditions deteriorated after 2200 with a ceiling overcast of 1,100 feet agl and lower. Similar conditions were reported at Napa County Airport (APC), Napa located about 24 miles east of the accident site and Charles M Schulz - Sonoma County Airport, Santa Rosa located about 24 miles north of the accident site.

Weather satellite imagery an hour prior to the accident shows an area of low stratiform type clouds forming along the coast and inland in the vicinity of the accident, with the cloud tops near 1,500 feet msl. Other satellite imagery at 1/2 hour before and after the accident time shows the stratiform type clouds along the coast and inland in the vicinity of the accident site.

According to the Astronomical Applications Department at the United States Naval Observatory, the official sunset was at 1959, the official end of civil twilight was at 2027, and the official moonrise was 0039.

COMMUNICATIONS

According to ATC communications, the pilot was in contact with Seattle ARTCC and was being transferred to the Oakland ARTCC. During the communication between the two controllers, the Seattle controller stated that he never did see the airplane on his radar due to a radar outage, and for the Oakland controller to expect to hear from the pilot 85 miles north of Mendocino. The radar outage covered the southern Oregon and northern California area, which the Seattle controller relied on. The Oakland controller could not see the airplane on his radar at the expected time, and informed the pilot that his transponder was not working. After some communication, the pilot recycled his transponder, and about 4 minutes later, the controller said they had him on radar. A transcript of the recorded transmissions between the pilot of N1160T and ATC is attached to the accident docket. The following partial transcripts are noted.

At 2049:45, while N1160T is passing over the Point Reyes area, the controller issued "…after point reyes you're cleared via the point reyes one arrival into san carlos," and N1160T acknowledged by repeating the clearance.

At 2112:44, N1160T was instructed by the controller to cross Stins intersection at 5,000 feet.

At 2121:07, the controller instructed the pilot to change frequencies and contact NORCAL approach, and the pilot acknowledged.

At 2121:23, N1160T had not changed frequencies and stated to the controller, "…got some engine trouble might need uh might need to divert."

At 2121:34, N1160T then stated, "one one six zero tango is calling in an emergency."

At 2121:37, the controller asked N1160T to state the nature of the emergency.

At 2121:45, the controller again asked N1160T to state the nature of the emergency.

At 2121:50, N1160T stated "losing engine power one one six zero tango."

At 2122:01, N1160T stated "what's my best routing from here…"

At 2122:04, the controller replied by stating "uh six zero tango i have santa rosa off your three five zero radial at about twenty miles". At this time, N1160T was traveling southbound and Santa Rosa was north his current position.

At 2122:10, N1160T requested the heading again, and the controller repeated.

At 2122:20, the controller queried "…uh you wanna go to gnoss that's about ten miles."

At 2122:45, N1160T stated "out of engine in and out of engine."

At 2122:48, the controller advised "…the uh gnoss airfield is at your zero seven five radial fourteen miles."

At 2123:00, N1160T replied "which one sorry?"

At 2123:02, the controller repeated the directions.

At 2123:50, the controller asked N1160T how many people were on board the airplane.

At 2123:52, N1160T stated "Just me."

At 2124:52, N1160T asked the controller "(unintelligible) am i heading november one one six zero tango, which direction?"

At 2124:57, the controller advised N1160T "…you're in the right direction right now for novato."

At 2125:35, the controller advised N1160T that the minimum vectoring altitude in his area was 3,400 feet. At this time N1160T was descending below 2,000 feet over mountainous terrain east of the Point Reyes area.

At 2125:59, the controller stated, "november six zero tango, you're uh coming left over like a you're on like a three six zero heading right now turn uh right heading of zero seven five."

At 2126:37, N1160T stated, "okay i appear to have uh engine back and uh and power."

At 2126:40, the controller requested "…fly heading zero seven five for novato airfield."

At 2127:16, N1160T queried the controller "what heading do you show me on for one one six zero tango."

At 2127:18, the controller stated to N1160T that he was on the 360° heading and gave him a heading of 085° for DVO.

At 2127:34, the controller queried N1160T "november one one six zero tango say your intentions do you wanna try to land novato or do you wanna go somewhere else."

At 2127:39, N1160T stated "uh novato would be fine but i've lost my compass".

At 2128:06, the controller i...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# WPR14FA349