NTSB Factual Report

HISTORY OF FLIGHT

On December 30, 1995, at 1204 hours Pacific standard time, a Beech V35B, N7337R, impacted terrain 1 mile east of the Delano, California, airport while executing an instrument approach. The aircraft was destroyed by impact and postcrash fire and the private pilot and three passengers were fatally injured. The flight originated at Cottonwood, Arizona, around 1030 mountain standard time and no flight plan was filed. Visual meteorological conditions prevailed en route; however, instrument meteorological conditions prevailed at the destination and the pilot requested an instrument approach.

A witness who was entering his house, which is under the missed approach flight path and about 100 yards from the crash site, told NTSB investigators that he heard the aircraft circling overhead followed by an increase in engine sound followed by the sound of impact. The sound of the engine was audible to impact.

Another witness, a worker in a nearby field, heard the aircraft approach from the south and fly northbound over the airport. The aircraft then started a right turn and was visible in the base of the clouds as it flew over the witness's position around 800 feet AGL. The witness described the aircraft flying in and out of the cloud bases until it made an abrupt pull-up into the clouds. The aircraft next appeared out of the clouds in a near vertical dive that continued to impact.

A third witness, a corporate pilot awaiting instrument release at Delano airport, reported that ceiling information was not available from the Automatic Weather Observation Service (AWOS-3). He estimated the ceiling at or below minimums for the VOR approach.

The aircraft was fueled to capacity 2 days before the accident in Cottonwood, Arizona, and flew a local flight of about 1 hour duration the next day. According to the operator of the airport, on the day of the accident, the pilot told him before departure that the weather was marginal at Delano and that he would land at Bakersfield if necessary.

PERSONNEL INFORMATION

The pilot held a private pilot license with airplane ratings for single engine land and instruments. The pilot's instrument rating was issued February 5, 1993. His third-class medical certificate was issued September 30, 1994, with limitations that the pilot use glasses for near and distant vision.

The pilot's medical certification records were obtained from the FAA's Medical Certification Branch and showed that the pilot had a medical history of lyme disease reported as recently as October 12, 1990. His subsequent medical applications on September 29, 1992, and September 30, 1994, reported that the lyme disease was "currently asymptomatic." At the medical examination on September 30, 1994, he reported a total flying time of 510 hours.

The pilot's logbook was substantially damaged (burned) in the accident. The last entry, date uncertain, was for a flight in his previously owned aircraft, a Piper PA-28-161, and indicates total flying time of 551.4 hours, simulated IFR time of 38.4 hours, and simulator time of 33.3 hours. No actual IFR flying time is shown.

One local pilot told the NTSB investigator that he had flown with the pilot as safety pilot while the pilot flew under the hood. They most recently flew together in early December for 1 or 1 1/2 hours in the Bonanza. He characterized the pilot as safety conscious and very cautious.

The pilot purchased the accident aircraft in August, 1995, and completed a 15-hour high performance checkout on October 26, 1995. The checkout was done in daylight, VFR conditions. The flight instructor who performed the high performance checkout told the pilot to get some experience in the aircraft and then come back for an instrument checkout in the Bonanza. According to the flight instructor, the instrument checkout was never accomplished.

Another flight instructor told the NTSB investigator that he had flown with the pilot on two occasions, both times in the Piper PA-28. The first time was on July 14, 1995, when the pilot completed a biennial flight review with 1 hour of ground instruction and 1 hour of flight instruction. The instructor's notes of the flight said "good flight, safe pilot". The second time was an instrument competency check conducted on October 30, 1995, which included 1 hour of ground instruction and 2 hours of flight instruction. Of the pilot, this instructor commented that "he didn't seem like a risk taker." This instructor never flew with the pilot in the Bonanza.

By coincidence, the flight instructor who administered the high performance checkout with the pilot was on the ground at Delano awaiting an instrument flight release at the time of the accident. He never saw the aircraft or heard any radio transmissions from it. The flight instructor told the NTSB investigator that the pilot had "very little" actual IFR flying time and none in high performance aircraft. He stated that the weather was near minimums for the approach and that the pilot "had no business" attempting the approach in the Bonanza. Of the pilot, the instructor said "I'm surprised, he's the last person I thought would do something [...] like this".

AIRCRAFT INFORMATION

At the time of the accident the aircraft had acquired 2,169 hours total time. The last major maintenance performed on the aircraft was an annual inspection on April 12, 1995, at which time the aircraft had 2,103 hours. Subsequent to the annual inspection there were six maintenance entries in the airframe logbook as follows: 1) On June 2, 1995 the biennial certification of the static system and transponder for instrument flight was performed; 2) On October 20, 1995 at 2128 hours, airworthiness directive 94-20-04 was complied with regarding inspection of the empennage and aft fuselage; 3) On November 10, 1995 at 2143 hours, the instrument pressure pump and filters were replaced; 4) On December 11, 1995, the KT-76 transponder was replaced with a KT-76A and recertified; 5) On December 13, 1995, a gap seal kit was installed in accordance with STC SA1176SO; and 6) On December 14, 1995 at 2150 hours, an "Oilamatic" engine pre-oiler system was installed in accordance with STC SA4094NM and a Shadin fuel flow indicating system was installed in accordance with STC SA449GL. There are also records in the FAA files of a Form 337 pertaining to installation of a "Berle Deshannon" windshield of which there is no record in the logbook.

METEOROLOGICAL CONDITIONS

Weather conditions along the route of flight from Cottonwood, Arizona, to the California desert were VFR. However, weather conditions in the San Joaquin Valley, where Delano is located, were characterized by low ceilings and multiple stratus layers below 6,000 feet with visibilities below the clouds of 1 to 4 miles in fog.

According to the airport manager, the ceilometer portion of the AWOS-3 system at Delano airport was inoperative at the time of the accident and no other weather observations were taken at the airport. However, a corporate pilot awaiting departure at the time of the accident estimated conditions as ceiling 800 foot broken and visibility 1.5 miles. From his position on the west-side ramp at the airport, the corporate pilot was able to see the smoke from the accident site 1.15 miles east of the airport.

Weather at Bakersfield, which is the nearest weather reporting station, at the time of the accident was: estimated ceiling 500 foot, broken, 4,500 foot, overcast and visibility 4 miles in fog; temperature was 57 degrees Fahrenheit; dew point 54 degrees Fahrenheit; wind from 230 degrees at 4 knots; and the altimeter setting 30.21 inHg. Bakersfield is located on the valley floor, 21 miles southeast of Delano. Elevation at Delano is 314 feet msl and Bakersfield is 507 feet msl.

COMMUNICATIONS

After crossing western Arizona and the California desert VFR, the pilot contacted Bakersfield Approach Control South Radar at 1140 hours while southeast of Bakersfield VFR above 8,000 feet msl, and requested a VOR instrument approach to Delano. At 1142 hours, the controller cleared the flight to descend to 8,000 feet and proceed direct to Shafter VOR. In the next 10 minutes there are several communications from Bakersfield Approach Control to the aircraft regarding the pilot's navigation to the VOR, and at 1156 hours the pilot transmitted "three seven romeo experiencing some disoriented or disorientation could you vector me please". The controller provided vectors to the final approach course and asked the pilot to report established on the approach course. At 1158, the pilot transmitted "yeah I've got her in (unintelligible) I think I'm established now thank you." The controller then cleared the aircraft for approach to Delano and issued further instructions for canceling IFR when landing was assured or on a missed approach. The pilot acknowledged the clearance. There were no further communications from the aircraft.

WRECKAGE AND IMPACT INFORMATION

The accident location is 1.15 miles east of the Delano airport on the south shoulder of Woollomes Road (east - west) approximately 1/4 mile east of Browning Road (north - south). The latitude is 35 degrees, 44.82 minutes north and the longitude is 119 degrees, 12.97 minutes west (GPS).

The central portion of the wreckage containing the engine, propeller, and cabin was approximately 6 feet off the paved shoulder of the road and the wings extended from the roadway proper (left wingtip) to the second row of plants in the adjacent vineyard (right wingtip). There were three severed electrical power lines that were repaired (spliced) directly above the central wreckage point. There were three slots in the leading edge of the left wing, back to the spar, at the midspan location. The slots exhibited peripheral burn marks and the spacing approximated the spacing of the overhead electrical power conductors. The empennage was inverted and laying on the right wing adjacent to the cabin area; however, according to the witness statement of the first person to arrive at the accident site, the tail of the aircraft was over the cabin area when he arrived. The center of the wreckage containing the engine, cabin, fuselage, and wings to the midspan station was consumed by postcrash fire.

All of the aircraft wreckage was present in the immediate vicinity of the impact point except the left and right fuel tank filler cap assemblies. The filler cap assemblies consisting of the cap, tank filler neck, and the panel that attaches them to the wing structure were both found 80 feet east of the remainder of the wreckage on the south shoulder of Woollomes Road.

Continuity of the flight controls was established at the accident site. Landing gear and flaps were retracted at impact. The aircraft's weight and center of gravity were calculated to have been within approved weight and CG limits. The vacuum pump shear coupling was damaged by fire and the rotor was fractured; however, the pump vanes were intact. There were scrape marks on the gyro rotor and rotor cage of the attitude gyro instrument. The alternator and voltage regulator were destroyed.

The light bulb in the alternator failure annunciator light and the transponder reply light were sent to the NTSB laboratory for evaluation. The laboratory report is attached and notes "clear evidence of hot stretching" in the alternator failure annunciator light bulb and "some evidence of hot stretching" in the transponder reply light bulb. The rotating beacon light bulbs, empennage navigation light bulb, and instrument panel light bulb filaments were intact.

The engine was disassembled and inspected at the Teledyne Continental Motors facility in Mobile, Alabama, in the presence of the NTSB investigator. The Teledyne Continental Motors report of the inspection is attached and concludes that "this engine did not exhibit any condition that would have caused an operational problem."

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by the Coroner Division of the Kern County Sheriff's Department and attributed the cause of death to blunt force injuries. A toxicological analysis of urine performed by the toxicology laboratory of the Coroner Division was negative for alcohol and barbiturates and was positive for caffeine and benzodiazepines.

A toxicological analysis was also performed by the FAA Civil Aeromedical Institute in Oklahoma City, Oklahoma. They reported no ethanol detected in urine and that they lacked a suitable specimen to test for carbon monoxide or cyanide. Their report was positive for three drugs: diazepam and nordiazepam were detected in liver fluid and nordiazepam and oxazepam were detected in the urine.

ADDITIONAL INFORMATION

The aircraft wreckage was released to Loss Management Services, Inc., on June 3, 1996.

NTSB Probable Cause

Failure of the pilot to maintain control of the aircraft during an IFR circling approach. A factor relating to the accident was: the pilot's lack of instrument flight experience in high performance aircraft.