N7FG

Destroyed
Fatal

BEECH A36TCS/N: EA-250

Accident Details

Date
Friday, November 20, 2015
NTSB Number
ERA16FA043
Location
Orlando, FL
Event ID
20151120X31605
Coordinates
28.520000, -81.404441
Aircraft Damage
Destroyed
Highest Injury
Fatal
Fatalities
2
Serious Injuries
0
Minor Injuries
0
Uninjured
0
Total Aboard
2

Probable Cause and Findings

The pilot's failure to maintain adequate airspeed while turning to join the final approach leg of the airport traffic pattern with full airplane-nose-up trim, which resulted in the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall. Contributing to the accident were the pilot's mis-use of the forward elevator flight control input with the autopilot engaged, which resulted in the full airplane-nose-up trim; his failure to recognize and correct the mis-trimmed airplane per the emergency procedures; and the excessive control forces required to maintain control of the airplane in the mis-trimmed condition, which resulted in pilot fatigue.

Aircraft Information

Registration
N7FG
Make
BEECH
Serial Number
EA-250
Engine Type
Reciprocating
Year Built
1981
Model / ICAO
A36TCBE36
Aircraft Type
Fixed Wing Single Engine
No. of Engines
1

Registered Owner (Historical)

Name
KAVAK AVIATION LLC
Address
120 SWAN MOUNTAIN DR
Status
Deregistered
City
KALISPELL
State / Zip Code
MT 59901-1306
Country
United States

Analysis

HISTORY OF FLIGHTOn November 20, 2015, about 1127 eastern standard time, a Beech A36TC, N7FG, descended into Clear Lake, Orlando, Florida. The private pilot and the passenger were fatally injured, and the airplane was destroyed. The airplane was registered to Kavak Aviation, LLC, and was being operated by the pilot as a 14 Code of Federal Regulations (CFR) Part 91 personal flight. Visual meteorological conditions prevailed at the time, and a visual flight rules (VFR) flight plan was filed. The flight originated from Orlando Executive Airport (ORL), Orlando, Florida, about 1115, and was destined for Gainesville Municipal Airport (GLE), Gainesville, Texas.

According to a chronological summary of flight communications, audio recordings, and transcriptions of communications, prepared by the Federal Aviation Administration (FAA), while in contact with ground control, the pilot was advised to remain outside of Class B airspace, provided departure instructions, and cleared to taxi to runway 7. The flight was then cleared for takeoff, and the pilot was instructed to turn left on course.

Radar data indicated that, between 1116:39 and 1118:43, the airplane proceeded in an east-northeasterly direction, turned to a northwesterly direction, and climbed from 200 ft to 1,800 ft mean sea level (msl). About 1118:47, while the airplane was flying in a northwesterly direction about 1,900 ft msl, the local controller advised the pilot, "november seven foxtrot golf remain outside Bravo airspace at or below one thousand five hundred and contact Orlando departure one one niner point four," and the pilot immediately replied, "alright one one niner point four what was the altitude restriction." The controller replied, "at or below one thousand five hundred," and, at 1118:59, the pilot replied, "at or below one thousand five hundred I'm already at two thousand" followed by a pause and then, "I'm descending for seven foxtrot golf (unintelligible)."

At 1119:09, when the airplane was about 2,100 ft msl, an Orlando Approach Control controller advised the local controller that the airplane needed to descend immediately, and the local controller replied, "yeah I'm starting him down."

While the airplane was flying in a northwesterly direction at 1,900 ft msl, the pilot established contact with Orlando Approach Control, and, at 1119:54, he advised the controller, "…seven foxtrot golf with you at uh one thousand eight hundred descending." The controller instructed the pilot to "ident," provided the Orlando altimeter setting, and asked him his request. The pilot replied by correctly reading back the altimeter setting and advised that he was requesting flight following. The controller asked the pilot for his destination, and the pilot said that it was GLE and asked to start his climb as there was an opening in the clouds. Between 1120:05, and 1120:30, the airplane climbed from 1,700 to 2,200 ft msl. The controller asked several times about the pilot's destination, and, at 1120:37, when the airplane was about 2,200 ft msl, the controller advised the pilot, "seven foxtrot golf okay, you have not been given a clearance through the Bravo why are you climbing;" the pilot did not reply. The controller then instructed the pilot to turn left to a heading of 270°, and the pilot did not reply. At 1120:51, the controller advised the pilot, "seven foxtrot golf I need you to listen cause you're in my Bravo without a clearance turn left heading 270." Between 1120:40 and 1120:53, the airplane descended from 2,200 ft msl to 1,700 ft msl.

At 1120:59, while the airplane was flying in a northwesterly direction at 1,700 ft msl, the pilot advised the controller that he was turning left to a heading of 270° and that "for some reason" he could not get the airplane's autopilot to disengage. The controller immediately replied, "thank you."

The controller provided the pilot with a transponder code, which the pilot read back, and the pilot then said, "listen I think we need to put this thing on the ground I don't know what's going on." The controller asked if the pilot wanted to return to ORL, and the pilot replied, "affirmative can you help me get there." The controller instructed the pilot to maintain VFR at 1,600 ft msl, to fly a heading of 210°, and to expect vectors to runway 7.

At 1121:53, when the airplane was about 1,800 ft msl, the pilot advised the controller, "ok listen um I have to use full force does anybody have any ideas what I can do to shut off this autopilot." The pilot then asked the controller for the assigned heading, which the controller provided, and, about 20 seconds after the pilot's request for assistance, the pilot of another airplane said, "pull your circuit breaker." At 1122:55, when the airplane was about 2,200 ft msl, the controller asked the pilot if he was able to descend, and the pilot replied, "…I'm trying I'm pushing as hard as I can on the yoke." The controller instructed the pilot to fly a heading of 180° when able, and the pilot replied, "descending to one eight I'm sorry going to one eight."

At 1123:34, the pilot of the other airplane advised the controller to have the pilot pull the circuit breaker. The accident pilot said that, "uh we pulled the circuit breaker but it just keeps uh porpoising up and down and it's taking full forward to go down and full back to go up to com compensate." The pilot of the other airplane advised the pilot to "power off the airplane" for 30 seconds, and the controller instructed the pilot to make a right turn to stay away from airplanes departing from Orlando International Airport.

At 1124:34, when the airplane was about 1,800 ft msl, the pilot stated, "we're powered way down." The pilot of the other airplane advised the pilot not to reduce engine power but to turn off the airplane's master switch, which would remove electrical power and disconnect the autopilot. The accident pilot asked the other pilot if he was referring to the key (ignition) switch, and the other pilot replied, "no don't turn the key to the off position just turn your master switch your electrical master switch off." The accident pilot asked if the other pilot was referring to the avionics master switch and said that he was "relatively new" to the airplane. The pilot of the other airplane clarified that the pilot was to turn off the battery and alternator switches.

Between 1124:34 and 1126:15 (the time of the last secondary radar return), the airplane descended from 1,800 to 1,100 ft msl and leveled off momentarily every 100 ft between 1,500 and 1,100 ft msl. At 1126:18, the controller advised the pilot that he was cleared to land on runway 7 at ORL. Primary radar returns (with no altitude reported) continued in a south-southeasterly direction from the location where the secondary radar returns ended, and, at 1126:58, the pilot said, "Orlando I'm (unintelligible)." The last primary radar return at 1127:02 was located about 0.1 nautical mile and 319° from the accident site location.

At 1127:11, the ORL local controller advised the approach controller, "ah he just rolled over straight down he's in the ground." Another air traffic controller said, "he rolled it over," and the local controller replied, "uh yeah it looked like he started a right turn to rejoin the final which turned into kind of a wing over uh it was nose down and uh he he went straight down and I lost sight of him…."

Several witnesses noticed the airplane immediately before it impacted Clear Lake. The witnesses saw the airplane in a "hard" right bank, which was followed by the airplane entering a vertical descent and impacting the lake. The witnesses did not see smoke trailing behind the airplane or parts separating during the descent.

Before first responders arrived, bystanders rushed to the area and recovered the occupants from the submerged wreckage. PERSONNEL INFORMATIONThe pilot, age 61, held a private pilot certificate with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. He held a third-class medical certificate, issued July 3, 2015, with a limitation to wear corrective lenses.

A review of the pilot's second logbook, which contained entries dated between November 3, 1995, and October 30, 2015, revealed that he logged a total time of about 1,541 hours of which 1,374 hours were in single-engine airplanes. No logged flights were noted between July 16, 2006, and March 9, 2012. The pilot logged three flights in 2013; the last one was on November 17, 2013. The pilot's next logged flight was on July 16, 2015, which was a sign-off for a flight review in accordance with 14 CFR Part 61.56.

Since purchasing the airplane on September 9, 2015, the pilot had logged about 37 hours in the airplane of which 12.5 hours were in the last 30 days. The remarks section of an entry in his pilot logbook for a flight 19 days after the airplane's purchase stated, "GPS + Autopilot Practice," and the logged duration was 4.2 hours. AIRCRAFT INFORMATIONThe airplane was certificated in accordance with Civil Air Regulations 3 and was manufactured by Beech in 1981. It was powered by a 300-horsepower Continental TSIO-520-UB engine and equipped with a Hartzell PHC-C3YF-1RF constant speed propeller.

A two-axis KFC 200 autopilot system was installed at manufacture in accordance with Supplemental Type Certificate SA1496CE. Components of the system consisted of a KA 285 mode annunciator, KI 256 flight command indicator, KC 290 mode controller, KC 295 flight computer, KS 270 pitch servo and mount, KS 272 trim servo and mount, and KS 271 roll servo and mount. The bridle cable of the KS 270 pitch servo attached to the primary elevator flight control cable by a clamp at each end of the bridle cable. A manual electric autopilot trim switch assembly installed on the pilot's left control yoke grip controlled the KS 272 trim servo, which was connected to the elevator trim actuator by a control cable. Actuation of trim using the switch required movement...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA16FA043