NTSB Factual Report

HISTORY OF FLIGHT

On February 11, 2004, about 2216 central standard time (CST), a Beech J35 airplane, N8389D, was destroyed when it collided with tree-covered terrain following a loss of control during a missed approach, about 14 miles north-northwest of the Pensacola Regional Airport, Pensacola, Florida. The airplane was being operated as an instrument flight rules (IFR) cross-country personal flight under Title 14, CFR Part 91, when the accident occurred. The non-instrument rated, solo private-certificated pilot, sustained fatal injuries. Dark night, instrument meteorological conditions prevailed at Pensacola, and an IFR flight plan was filed. The flight originated at the New Smyrna Beach Municipal Airport, New Smyrna Beach, Florida, about 1920 eastern standard time (EST), and was en route to the Louis Armstrong New Orleans International Airport, New Orleans, Louisiana.

According to personnel at the Pensacola Terminal Radar Approach Control (TRACON), the accident pilot contacted the Pensacola TRACON specialist on duty about 2125 CST, and requested that his IFR flight plan be "amended." When the TRACON specialist inquired as to what the amendment was, the pilot reported that he was low on fuel and he needed to land at Pensacola. According to personnel at the Pensacola TRACON, as the accident pilot was maneuvering for the ILS approach for runway 17 at Pensacola, radar and radio contact was lost with the accident airplane. The last reported position was about 14 miles north-northwest of the Pensacola Regional Airport.

CREW INFORMATION

The pilot held a private pilot certificate with an airplane single-engine land rating. According to FAA records, the pilot did not possess an instrument rating.

The most recent medical certificate issued to the pilot was a second-class medical certificate issued on August 28, 2003, with no limitations.

The pilot's heavily damaged personal flight logbook was located at the accident site. According to the logbook, his total aeronautical experience consisted of about 506 flight hours, with about 450 in the accident airplane make and model. In the preceding 90 and 30 days prior to the accident, the logbook lists about 12 and 5 hours, respectively.

The logbook also revealed that the pilot was in the process of receiving flight instruction for an instrument rating. According to the logbook entries, the pilot logged about 31.5 hours of "actual instrument" flight time during previous flights. During a telephone conversation with the NTSB IIC, the accident pilot's flight instructor said that he had been providing flight instruction to the accident pilot since December 2003. He added that some of the flight instruction was conducted in the accident airplane. The instructor noted that the accident pilot had been practicing the flight route to New Orleans using a Microsoft Flight Simulator 2000 program, on his personal computer.

AIRCRAFT INFORMATION

The airplane was manufactured in 1958. According to the last entry in the airplane's airframe logbook on February 9, two days before the accident, the airplane had accumulated a total time in service of 4,121.3 flight hours. Examination of the maintenance records disclosed that the most recent annual inspection of the airframe and engine was accomplished on March 3, 2003, 12.7 hours before the accident.

The engine had accrued a total time of 750.8 hours. The maintenance records note that a major overhaul was accomplished on June 13, 1991, 640.4 hours before the accident.

According to the airplane's airframe logbook, the accident airplane was equipped with two wingtip mounted, 20 gallon auxiliary fuel tanks, manufactured by J.L.Osborne Tank and Supply, giving the accident airplane a total fuel capacity of 100.0 gallons, or about 87.0 gallons of usable fuel.

The flight instructor that had provided flight instruction services to the pilot, reported to the NTSB IIC that on a previous flight in the accident airplane, they encountered a fuel transfer problem that involved the right tip-tank. In a written statement he wrote, in part: "When we selected the right tip-tank, the engine began to cough and lose power. We immediately selected the main tank, and the engine ran smooth again." According to the flight instructor, the pilot had his mechanic lubricate the fuel selector valve assembly, and the fuel system operated normally. A review of the maintenance records failed to disclose any maintenance entry correcting the deficiency noted by the flight instructor.

METEOROLOGICAL INFORMATION

The closest official weather observation station is located at the Pensacola Regional Airport, which is about 14 miles south-southeast of the accident site. At 2205, an Aviation Routine Weather Report (METAR) at Pensacola was reporting, in part: wind, 090 degrees (true) at 10 knots; visibility, 3/4 statute miles with mist; clouds and sky condition, 100 feet overcast; temperature, 55 degrees F; dew point, 55 degrees F; altimeter, 29.98 inHg.

Crestview, Florida, is located about 39 miles northeast of the accident site. At 2209, a special weather observation was reporting, in part: wind, 100 degrees (true) at 5 knots; visibility, 1 and 3/4 statute miles with breaks in the overcast at 200 feet; temperature, 55 degrees F; dew point, 54 degrees F; altimeter, 30.02 inHg.

According to several residents that heard the accident airplane just before the accident, all consistently characterized the weather conditions as very low visibility with drizzle, fog, and very low ceilings.

COMMUNICATIONS / ARCHIVED RADAR DATA

The NTSB IIC reviewed air-to-ground communications tapes, transcripts, and archived radar data maintained by the Federal Aviation Administration (FAA). The transcripts revealed that at 1820, while airborne, the pilot contacted the Daytona Beach Arrival-South sector. The pilot reported that he was in the vicinity of the New Smyrna Airport, and he requested an IFR clearance to the Louis Armstrong New Orleans International Airport, New Orleans. After positive radar identification was established, the accident pilot was issued an IFR clearance as requested, and was initially assigned en route altitudes of 3,000 feet msl and 5,000 feet msl, respectively.

At 2058, as the accident flight progressed along the coastline, toward New Orleans at 6,000 feet msl, the Air Route Traffic Control Center (ARTCC) specialist who was monitoring the accident airplane's progress using radar, noticed that the airplane had changed direction, and was now headed eastbound. The ARTCC specialist contacted the pilot and asked the pilot if there was a problem, and the pilot replied by saying that he had a fuel issue and he was working on the problem. The ARTCC specialist responded by telling the pilot that if he needed to land, the Panama City Airport was about 7 to 10 miles east of the pilot's current position. The pilot then told the ARTCC specialist that he believed he could make it to the Gulfport-Biloxi International Airport. The ARTCC specialist then asked the pilot if he would like to proceed direct to the Gulfport-Biloxi International Airport. At 2101, the pilot contacted ARTCC specialist and reported that he had "fixed the problem" and that he would like to proceed direct to his original destination of New Orleans. The ARTCC specialist granted the accident pilot's request. At 2125, the ARTCC specialist transferred communications to the Pensacola TRACON specialist on duty in that sector.

At 2128, the accident pilot established initial contact with the Pensacola TRACON specialist by stating, in part: "Can I amend it to you for fuel?" The Pensacola TRACON specialist responded to the pilot's request by asking the accident pilot to clarify what it was that he wanted to amend. The pilot responded: "I wanna... I would like to amend my flight paa...my flight plan to come to you for fuel...you have ah, Av Gas there?" The Pensacola TRACON specialist said, in part: "Yes sir, you wanna land at Pensacola Regional Airport, is that correct?" The pilot responded and said, in part: "I'm uh I'm having a fuel situation up here and I need to get this thing taken care of." The accident airplane was then given priority handling over other arriving aircraft at Pensacola, and was then cleared for the instrument landing system (ILS) approach to runway 17. At 2129, the Pensacola TRACON specialist states, in part: "Bonanza 89D roger, expect vectors ILS 17 approach at Pensacola Regional Airport, wind 100 at 12, visibility 2 miles mist, ceiling two hundred overcast, altimeter 29.99."

At 2135, the TRACON specialist asked the pilot: "Bonanza 89D, are you still in VMC conditions there Sir?" The pilot responded by saying: "Uhhhhh, still visual here, but that's all I can tell you now, yes." At 2137, the TRACON specialist asked the pilot: "Bonanza 89D were you just burning more fuel than you'd uh estimated?" The pilot responded by saying: "I have fuel in a tip tank that I can not get to."

Between 2142 and 2157, the tapes and radar data revealed that the TRACON specialist provided the accident pilot with radar vectors in an attempt to intercept the glide slope and localizer for the ILS approach to runway 17. During the first intercept attempt, the TRACON specialist instructed the pilot to descend to 1,700 feet msl, and provided the pilot with directional heading changes in order to intercept the localizer for the ILS approach to runway 17.

When the airplane is about 8 miles to the north of the airport, the TRACON specialist stated: "Bonanza 89D, assigned altitude is 1,700, you're on a base leg, 8 miles north of the airport." The pilot then responded with: "Roger, 89D 1,700, base leg is north." The TRACON specialist then stated: "Bonanza 89D, I'm showing you at 2,700, you want a vector across the final for descent, or can you get down from there?" The pilot said, in part: "I'm uh, still working er down, I think uh... yes, go ahead and give me a vector for descent." During the conversation, the pilot said: "...roger, 89D, do you have a frequency for that ILS?" The TRACON specialist stated: "Yesser, its 111.1." At 2151, the TRACON specialist stated: Bonanza 89D, you appear to be off course, Sir. Uh, you're right at Brent [intersection] you want me to vector you back around and try to resequence you again?" The pilot stated: "That's affirmative, I'm outa gas." The TRACON specialist responded to the pilot by saying: "You say you're out of gas?" The pilot stated: "Just about." The TRACON specialist said: "Alright, you wanta continue the approach?" The pilot responded: "Affirmative." The pilot was instructed to turn left in order to intercept the localizer. The pilot reported to the TRACON specialist that: "I've got the needle." The TRACON specialist replied: "89D, you look like your northbound sir, you going away from the airport, you need to turn around, you need to go back to the south, sir." The pilot said: "Roger that, 89D turning left 130."

The TRACON specialist continued to give vectors to assist the pilot in turning the airplane around, to a southerly direction. The TRACON specialist then told the pilot: "Alright 89D, report established on the localizer, and just stay with me sir, on my frequency." The pilot responded by saying, in part: "Okay, I'm descending quickly....I'm having a real hard time up here with fuel..." The TRACON specialist stated: Bonanza 89D caution, low altitude alert, the minimum vectoring altitude in your area is 1,700, your mode C is indicating 1,200, over." The pilot then reports to the TRACON specialist: "89D, we're climbing." The TRACON specialist said: "Bonanza 89D, you appear to be turning back to the northeast sir, can you turn right to 130 degrees?" The pilot told the TRACON specialist: "Okay, I'm trying to turn right to 130, I'm just having a helluva time up here."

The TRACON specialist provided additional vectors to assist the pilot in getting established on an inbound track towards the airport. The TRACON specialist then told the pilot: "89D, turn right to 170, you look like you're right on the centerline now sir, are you established on the localizer?" The pilot responds by saying: "Affirmative." The TRACON specialist tells the pilot: "Awright, start your descent...89D, you're 2 miles from the runway. The TRACON specialist then tells the pilot: "Bonanza 89D, cleared to land runway 17, winds are 090 at 8.... looks like your drifting off..off course, to the west, over." The pilot responded: "...Affirmative, I trying to...." The TRACON specialist: "Bonanza 89D, climb immediately and maintain 1,700, climb and maintain 1,700 immediately, over...Bonanza 89D, how do you hear me?" The pilot said: "Affirmative, I'm climbing." The TRACON specialist then told the pilot: "Roger, turn right heading 330, turn to 330, let's try it again."

Between 2157 and 2209, the tapes and radar data revealed that the TRACON specialist provided the accident pilot with radar vectors in an attempt to intercept the glide slope and localizer for the ILS approach to runway 17. The second approach also resulted in a missed approach.

During the third attempt to establish the accident pilot on a stabilized approach for the ILS approach to runway 17, the TRACON specialist told the pilot: "Bonanza 89D, turn right heading 040." The accident pilot said: "040, 89D...I'm outta gas.... we're on fumes here." The TRACON specialist responded: "Bonanza 89D roger, turn right heading 090. The accident pilot said: "090, 89D." The TRACON specialist then asks the pilot: "Bonanza 89D say altitude." The only response from the accident pilot is: ".... two..." The TRACON specialist: "Bonanza 89D, maintain 1,700, over." At 2216, the accident pilot told the TRACON specialist, in part, "I can't, I can't...I've lost it...." No further radio contact was received from the accident airplane, and the airplane disappeared from the TRACON specialist's radar screen.

A complete transcript of the air-to-ground communications between the accident pilot and the Pensacola TRACON specialist is included in the public docket for this accident.

WRECKAGE AND IMPACT INFORMATION

The National Transportation Safety Board investigator-in-charge (IIC), along with two Federal Aviation Administration (FAA) airworthiness inspectors from the Alabama Flight Standards District Office, examined the airplane wreckage at the accident site on February 12, 2004. All of the airplane's major components were located at the main wreckage site.

The airplane collided with trees in an area of dense, tree-covered, swampy terrain. The wreckage debris path was on a magnetic heading of 270 degrees. (All headings/bearings noted in the report are oriented towards magnetic north) Fragmented portions of the airplane wreckage were widely scattered along the wreckage path. The debris trail measured about 100 feet long.

The wreckage path displayed signs of extensive fuselage, wing, and empennage fragmentation along its entire length. Smaller shreds of aircraft aluminum were observed hanging from the 75-foot tall trees. Larger portions of airplane debris, including extensive amounts of shredded aircraft aluminum, a doorframe assembly, landing gear components, fuel system components, and aircraft instrumentation, were within the wreckage path.

About mid-way along the wreckage path, a crater was located that measured about 8 feet in diameter, and 3-feet deep.

The propeller assembly was buried in the 3-foot deep crater. The propeller crankshaft flange was broken. Both blades were loose in the hub, but remained attached to the hub and propeller blade assembly. Both propeller blades displayed multiple leading edge gouges, and torsional "S" bending.

The debris path between the crater and the main wreckage point of rest, had additional fuselage fragmentation.

The main cockpit/cabin area of the fuselage was extensively fragmented, and due to the damage, flight control continuity could not be confirmed.

The engine was separated from the fuselage, and was positioned the farthest away from the initial impact point. It sustained impact damage to the forward, and underside portion of the engine. The intake and

NTSB Probable Cause

The pilot's improper decision to conduct flight that exceeded his demonstrated skills/ability. Also causal was his failure to properly execute the instrument approach. Contributing factors were low ceiling, fog, and the pilot's lack of the appropriate certification for the flight.