N36HT

Destroyed
Fatal

BEECH A36S/N: E-1986

Accident Details

Date
Monday, September 7, 2015
NTSB Number
ERA15FA340
Location
Kernersville, NC
Event ID
20150907X44940
Coordinates
36.023612, -80.068054
Aircraft Damage
Destroyed
Highest Injury
Fatal
Fatalities
3
Serious Injuries
0
Minor Injuries
0
Uninjured
0
Total Aboard
3

Probable Cause and Findings

The pilot's loss of airplane control due to spatial disorientation, which resulted in an aerodynamic stall/spin. Contributing to the accident was deficient Federal Aviation Administration air traffic control training on recognition and handling of emergencies, which led to incorrect controller actions that likely aggravated the pilot's spatial disorientation.

Aircraft Information

Registration
N36HT
Make
BEECH
Serial Number
E-1986
Engine Type
Reciprocating
Year Built
1981
Model / ICAO
A36BE36
Aircraft Type
Fixed Wing Single Engine
No. of Engines
1

Registered Owner (Historical)

Name
CENTRAL PENN AVIATION ACADEMY INC
Address
1387 AIRPORT RD
Status
Deregistered
City
PAXINOS
State / Zip Code
PA 17860-7212
Country
United States

Analysis

**This report was modified on August 31, 2016. Please see the docket for this accident to view the original report.**

HISTORY OF FLIGHT

On September 7, 2015, about 1203 eastern daylight time, N36HT, a Beech A36, was destroyed when it impacted terrain near Kernersville, North Carolina. The private pilot and the two passengers were fatally injured. The airplane was registered to Central Penn Aviation Academy Inc., Paxinos, Pennsylvania and operated by the pilot. An instrument flight rules (IFR) flight plan was filed for the flight that departed Sarasota-Bradenton International Airport (SRQ), Sarasota, Florida, about 0819, under the provisions of a 14 Code of Federal Regulations Part 91 personal flight. Instrument meteorological conditions (IMC) prevailed at the time of the accident.

According to radar and voice communication data provided by the Federal Aviation Administration (FAA), the airplane was being radar vectored by air traffic control for the ILS RWY 5R instrument approach to the Piedmont Triad International Airport (GSO), Greensboro, North Carolina, following a previous unsuccessful ILS approach to the same runway.

The pilot contacted GSO approach at 1132:54 and reported that he was descending through 5,700 ft. A controller replied that automated terminal information system (ATIS) information Delta was current, the altimeter setting was 30.19, and the pilot should expect to land on runway 5R. The pilot read back the runway assignment, and then asked if he should expect a visual approach. The controller stated that the pilot should expect the ILS approach, and asked the pilot to report when he had received information Delta. The pilot confirmed that he had information Delta, and then asked if the assigned runway was 5L. The controller reconfirmed the original assignment, runway 5R.

At 1133:51, the pilot asked the controller to confirm that he was cleared to descend to 5,000 ft. The controller responded that if 5,000 was the altitude assigned by the previous controller, it was correct, and also noted that he had not issued any other altitude instructions. The pilot acknowledged.

At 1135:14, the pilot again asked the controller to confirm whether he should expect runway 5R or 5L.The controller responded, "The right side – R I G H T." The pilot read back, "Five right 36HT."

At 1140:44, the controller instructed the pilot of N36HT to fly heading 360 for sequencing into GSO, and the pilot acknowledged. At 1143:26, the controller instructed the pilot to contact another controller on frequency 124.35.

The pilot contacted the controller at 1144:00 while the airplane was level at 5,000 ft. The controller provided the GSO altimeter setting, 30.19. At 1145:24, the controller cleared the pilot to descend to 3,000 ft. At 1148:01, the controller advised the pilot of potentially conflicting traffic ahead, type and altitude unknown. The pilot responded, "Roger – 36HT is about to go IMC." The airplane was descending through 3,600 ft at the time.

At 1148:38, the controller advised the pilot that traffic was no longer a factor and instructed him to turn right heading 010 degrees. The pilot correctly read back the heading. At 1149:04, the pilot reported level at 3,000 ft, and then asked if the controller wanted him to remain at 3,000 ft. The controller responded, "Affirmative."

At 1150:35, the controller transmitted, "N36HT niner miles from Pagan, turn right heading 020, maintain 3,000 until established on the localizer, cleared ILS runway 5R approach. The pilot responded, "Turning right heading 020 for Pagan." The controller restated the altitude restriction and the approach clearance, and the pilot correctly read it back.

At 1152:48, the pilot asked, "How do you like this route of flight?" The controller responded, "You look just a little bit right of course for the ILS, turn left heading 0…make that 360 for the ILS, report established." The pilot then asked, "Turning left or turning right for 360?" The controller replied, "left to 360," and the pilot acknowledged.

At 1153:59, the controller asked the pilot, "…are you established? [on the localizer]" The pilot responded, "Established if I could have vectors to final, please." The controller then asked, "…Are you established on the localizer?" The pilot stated, "I believe I am, 36HT." The controller continued, "Now you look like you just actually went through the localizer." The pilot replied, "Roger – request a vector for final for 36HT." The controller issued an instruction to another airplane, then at 1154:30 transmitted, "N36HT cancel your clearance, maintain 3,000, turn left heading 320 for sequencing." The pilot read back, "Left 320."

At 1156:42, the controller instructed the pilot to turn left heading 230 degrees for vectors to the ILS runway 5R approach. The pilot correctly read back the instruction.

At 1157:30, the controller asked the pilot to verify that he was flying heading 230. The pilot replied, "Negative, and 36HT is close to..." The transmission ended incomplete. The controller then took a coordination call from another facility. During that call, the pilot called again in a strained tone, stating, "N36HT request vectors," and the controller also noticed that the airplane's altitude was below 3,000 ft. He ended the call and at 1157:57 responded to the pilot, "Bonanza 36HT you need to be level at 3,000, altitude shows you 2,500, Greensboro altimeter 30.19." The pilot responded, "6HT climbing to three." The controller asked the pilot to verify that he was on a 230 heading. The pilot did not respond.

At 1158:40, the controller asked the pilot to verify the airplane was at 2,900 ft. The pilot did so. At 1159:16, the controller asked the pilot to verify the airplane's heading. The pilot responded that the airplane was heading 166. The pilot continued, "We need a descent, we are almost disoriented, N36HT…2,700." In the background of the transmission, a female voice said, "Turn something off."

At 1159:43, the controller instructed the pilot to start a left turn and 16 seconds later told him to maintain 2,500 ft. The pilot did not acknowledge the turn, but radar data indicated the pilot initiated a left turn. At 1200:16, the controller instructed the pilot to start a right turn. The pilot responded, "Right turn, 36HT leveling off 2,500." At 1200:47, the controller transmitted a low altitude alert to N36HT along with the altimeter setting, and asked the pilot to say altitude. The pilot did not acknowledge the transmission, and radar data showed that during the next minute the airplane initially turned right but then entered and completed a 360-degree left turn.

At 1201:25, the controller transmitted, "N36HT climb and maintain 4,000, I can see if I get you back up into the uh above the clouds." At 1201:35, the controller continued, "N36HT Greensboro approach you up? Last altitude showed 2,100." At 1201:41, the pilot transmitted "N36HT" in an agitated voice. The controller replied, "N36HT just climb and maintain 4,000, I'll block altitude for you."

At 1202:06, the controller asked the pilot of N36HT, "… if he was able to take the climb", and continued, "Last tops were reported at 3,500, if I can get you up to 4,000 maybe you can square it back off." At 1202:18 a short sound was heard, possibly from the pilot. At 1202:39, the controller advised the pilot that his altitude was 2,100 ft.

At 1202:44, an unidentified transmission of what sounded like breathing was heard on the frequency. At 1202:54, the pilot asked, "Is there a nearby field for 36 ho-." The controller responded, "…the nearest airport is Greensboro airport, off your left wing and off your current heading 7 miles. Right now showing 1000 overcast for the ceiling."

At 1203:21, the controller asked the pilot for his altitude. At 1203:34, screams were heard on the frequency. There were no further communications with the pilot.

Several witnesses observed the airplane just prior to the accident. One witness stated that when he first saw the airplane, it was "very low" in the sky and was in a "sharp left turn" toward the west. He said the airplane was banking so sharply that the wings appeared to be vertical to the ground. A second witness stated that the airplane was flying low and was beneath the "low clouds." She said the airplane, "...looked as if it were a trick plane practicing stunts or else someone trying to stabilize the plane but continuing to overcorrect as the nose would go down then up and the wings would go from right to left and back, but it never stabilized." She also said the airplane was going "very slow." She last saw the airplane descend behind a tree line and out of her view, but she could still hear its engine. She described the sound being similar to when a lawn mower engine "quits right before it runs out of gas." She said the engine revved up and then slowed, revved up and slowed, and then about 5 to 10 seconds later she heard a loud pop similar to a bottle rocket.

A third witness was in his front yard when he saw the airplane flying from right to left away from the airport. He said the airplane appeared to be flying normally and the engine was operating as if "everything was normal." A few minutes later the airplane turned back toward the airport. The witness said that before the airplane's wings leveled, the left wing dropped, followed by the right wing in a swaying motion. The witness said that as the right wing was coming back up to level, the airplane descended below the tree line and disappeared from view followed by the sound of an impact.

A fourth witness was in her front yard when she observed the airplane in a "severe" bank to the right heading toward the southeast. She said the airplane made a sharp right turn and "spiraled downward making 3 to 4 rotations" before it disappeared from view behind trees. Shortly after, the witness observed black smoke coming up from behind the trees where she last saw the airplane.

...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA15FA340