NTSB Factual Report

HISTORY OF FLIGHT

On March 28, 2003, about 1549 central standard time, a Beech A36, N1636W, operated by Morris Hancock Flying Club as a rental airplane, was destroyed following an uncontrolled descent into terrain about two miles west of New Vienna, Iowa. Marginal visual meteorological conditions prevailed at the time of the accident. The Title 14 Code of Federal Regulation (CFR) Part 91 business flight was operating on an instrument flight rules flight (IFR) plan. The commercial pilot and two passengers were fatally injured. The flight departed from Aurora Municipal Airport, Aurora, Illinois, en route to Morris Municipal Airport (3CK), Morris, Minnesota, at 1439.

A private pilot, who had known the accident pilot through the Morris Hancock Flying Club, stated that the accident pilot was to fly the passengers on a business trip. According to the private pilot, the accident pilot said that he would charge for the day, plus an hourly rate for the airplane, which the private pilot knew was the rental rate for the accident airplane at the flying club. When the pilot was told about the flight and that one of the passengers wanted to be able to get home in good time Friday afternoon, the pilot mentioned something to the effect that there were some fronts moving through that might affect the route of flight and that he 'didn't want to fly in any ice.' The pilot had some students scheduled for lessons on the day of the accident and thought those could be changed.

The president of the Morris Hancock Flying Club provided the investigator-in-charge with a copy of the sign up calendar for the accident airplane. An entry for March 28 shows the following: 6 am, the pilot's name, an arrow, and 6 pm.

According to the Federal Aviation Administration’s Aircraft Accident Package:

At 1211, the pilot of N1636W called the Kankakee Automated Flight Service Station (AFSS) by telephone and obtained a preflight briefing from the Lake-in-the-Hills airport (3CK) to the Morris, MN airport (MOX).

At 1322, the pilot of N1636W called the Kankakee AFSS by telephone and obtained an abbreviated preflight weather brief from 3CK to Aurora airport (ARR)

At 1432, N1636W called Aurora Air Traffic Control Tower (ATCT) Ground Control for IFR clearance.

At 1439, Aurora ATCT cleared N1636W for takeoff with initial heading of 270 degrees.

At 1511, N1636W advised that he was picking up light rime icing at 6,000 feet and that he would like to try 4,000 feet. Approach Control instructed N1636W to descend and maintain 4,000 feet, and coordinated the altitude change with Chicago Center.

At 1517:20, N1636W transmitted, "chicago center bonanza one six three six whiskey with you level four thousand."

At 1517:24, Chicago Air Route Traffic Control Center (Chicago ARTCC) transmitted, "bonanza one six three six whiskey chicago center good afternoon your radar contact is lost due to your prox uh proximity to your radar site and your altitude i should be able to pick you up here as you uh come to uh closer to dubuque."

At 1521:36, Chicago ARTCC transmitted, "(unintelligible) one six three six uh whiskey are radar contact now east southeast of the dubuque and i'm showing uh twenty three miles four thousand thank you."

At 1521:54, Chicago ARTCC transmitted, "and one six three six whiskey copy that."

At 1521:57, N1636W transmitted, "three six whiskey i copy that yes twenty four uh south southwest of dubuque."

At 1542:55, N1636W transmitted, "chicago center uh bonanza one six three six whiskey would like to try six thousand."

At 1543:11, N1636W transmitted, "bonanza one six three six whiskey would like to try six thousand feet to uh get between layers."

At 1543:16, Chicago ARTCC transmitted, "bonanza one six three six whisky climb and maintain six thousand."

At 1543:20, N1636W transmitted, "three six whiskey out of four for six."

At 1549:35, Chicago ARTCC transmitted, "november one six three six whiskey i've lost your transponder reset transponder squawk six two four one.

There were no further recorded transmissions by N1636W.

According to an Iowa State Highway Patrol Statement/Interview, a witness was working outside when he heard the airplane. "The airplane came right out of the clouds." The report also states that "the engines were revved up to the maximum."

A second witness said that he was working on the north side of his barn when he heard an airplane come up from the southeast heading towards the northwest about 1530. He said the airplane was white in color and didn't pay attention to its trim color. He heard the airplane "pulling hard" and didn't know if it had a muffler on it. The airplane was 1,500-2,000 feet above the ground in level flight. He saw the airplane flying through the clouds and heading for a clearing. He said that there was a wall of dark clouds along route 20 which were low to the ground. The clouds over Dyersville, Iowa, were black. He described the weather as sleeting with water, pellets, and snow. He was looking through the rain and sleet and estimated that the visibility at the time was 2-3 miles.

The main wreckage was located about 22.4 nautical miles (NM) and 291 degrees from Dubuque Regional Airport (DBQ), Dubuque, Iowa, at an accident site elevation of 1,022 feet mean sea level.

PERSONNEL INFORMATION

The pilot, age 44, reported on his last airman medical application that he was self-employed as a flight instructor; he was one of the flight instructors at Morris Hancock Flying Club. He held a commercial pilot certificate with airplane single-engine land, multiengine land, and instrument airplane ratings. He held a certified flight instructor certificate (CFI) with a single-engine rating.

On April 28, 1982, he was issued a private pilot certificate with an airplane single-engine land rating. A total instruction time of 38.5 hours and a total pilot-in-command (PIC) time of 34.5 hours was reported on his Airman Certificate and/or Rating Application.

On September 7, 1982, he was issued an instrument airplane rating. A total instruction time of 105.4 hours and a total PIC time of 164.1 hours were reported on his Airman Certificate and/or Rating Application.

On January 31, 2001, he was issued a commercial pilot certificate. A total instruction time of 136 hours and a total pilot time of 474 hours were reported on his Airman Certificate and/or Rating Application.

On April 26, 2001, he failed his practical examination portion on his first attempt to obtain a commercial airplane multiengine rating. Upon reapplication, he was to be reexamined on the following: "AREA OF OPERATION IX UNSATISFACTORY ALL OTHERS SATISFACTORY." A total instruction time of 150 hours and a total pilot time of 516 hours were reported on his Airman Certificate and/or Rating Application.

On May 2, 2001, he was issued a multiengine land rating upon his reexamination.

On April 9, 2002, he failed his practical examination for an initial flight instructor certificate with an airplane single-engine rating. A total time of 803 hours was reported on his Airman Certificate and/or Rating Application. Upon reapplication, he was to be reexamined on the following: "AREA XIII. EMERGENCY PROCEDURES, AREA XIV. APPROACHES AND LANDINGS." A total instruction time of 224 hours and a total pilot time of 803 hours was reported on his Airman Certificate and/or Rating Application.

On April 15, 2002, he was issued a CFI certificate with an airplane single-engine rating. A total instruction time of 227 hours and a total pilot time of 818 hours were reported on his Airman Certificate and/or Rating Application.

On September 29, 2002, he was involved in a general aviation accident during an instructional flight in which he was acting as the CFI. This accident was investigated by the National Transportation Safety Board, which determined the probable cause of the accident as: "The inadequate fuel management by the certified flight instructor."

On November 27, 2002, he passed a reexamination of Flight Instructor Practical Test Standards for aircraft, with emphasis on Area of Operation III, Task D and Area of Operation XIII, Task A&B. A total pilot time of 1,168 hours was reported on his Airman Certificate and/or Rating Application.

The pilot's last two logged flights in the accident airplane were on March 16 and March 17, 2003. The flights were logged from MOX to RAP and from RAP to MOX the total duration of both flights was logged as pilot-in-command and no flight instructor time.

His last pilot logbook entry is dated March 27, 2003, showing a local flight from MOX in a Cessna 172 with a total flight duration of 1.1 hours, all of which was logged as flight instructor. According to logbook information, the pilot accumulated a total flight time of 1,419.6 hours, 211.8 hours in the last 90 days, and 75.3 hours in the last 30 days. He accumulated a total cross country flight time of 657 hours. He accumulated a total flight time in actual instrument conditions of 39.7 hours, of which 2.7 hours were in the last 90 days, and 1.9 hours were in the last 30 days. He accumulated a total simulated instrument (hood) time of 58.7 hours, of which 0 hours were in the last 90 and 30 days.

The pilot was issued a second class medical certificate on December 5, 2002, with the following limitation: "Holder shall wear lenses which correct for distant vision while exercising the privileges of his airman certificate."

AIRCRAFT INFORMATION

The 1972 Beech A36, serial number E-348, was registered to the Morris Hancock Flying Club where it was operated as a club rental airplane. The six-place airplane was powered by a Continental IO-520-BA engine, serial number 280919R. The following inspections were recorded in the airplane logbooks:

On February 8, 2001, the airplane received a pitot static system check required by Federal Aviation Regulation (FAR) 91.411.

On February 25, 2003, the airplane and engine received an annual inspection. The airframe had a total time of 5,233.7 hours and a tachometer time of 946.7 hours. The engine had a total time of 2,074.7 hours, time since major overhaul of 314.2 hours, and a tachometer time of 947.7 hours.

The airplane was equipped with an Apollo global positioning system receiver 2001 NMS receiver. The receiver’s data card listed the following: North America, Class D, Part Number 138-0427, Version 1.1; Date 02/22/01-03/21/01.

The airplane was not equipped with a wing ice protection system. The Beech A36 Pilot Operating Handbook states, "WARNING FLIGHT IN ICING CONDITIONS IS PROHIBITED."

METEOROLOGICAL CONDITIONS

According to the National Transportation Safety Board's Meteorological Factual Group Chairman Report, which is included in the docket of this report:

The National Weather Surface Analysis chart for 1500 shows a strong cold front extending from northern Michigan southward across western Kentucky. In addition, a secondary pressure trough extended from the low over northern Lake Michigan southwestward through northeastern Iowa.

Station plots indicate overcast clouds, patchy precipitation, and moderate northwesterly winds over Iowa and Minnesota. At 1500, surface temperatures were in the low 30s Fahrenheit over northern Iowa and Minnesota.

The 850 millibar (about 5,000 feet) Analysis charts for 0600 and 1800 show an area of low pressure over the northern Great Lakes with a deep trough extending southward into Texas-Louisiana. The station plots indicate northwesterly winds at 25-35 knots westward of the trough axis over the northern Midwest. Temperature contours indicate strong cold air advection along the trough axis.

The North Central Area Forecast, issued at 0445, valid until 1700 for clouds/weather and 1700-2300 for the outlook.

MN

Extreme northwestern Minnesota...sky clear. Occasion above ground level scattered 2,000-3,000 feet. Outlook...visual flight rules. Rest of Minnesota...ceilings overcast 1,500-2,500 feet. Tops 8,000-10,000 feet. Broken 15,000 feet. Tops FL200. Broken cirrus. 045 degrees at 15 knots gusting 25 knots. Chance light snow mist mainly eastern Minnesota. Outlook...marginal visual flight rules ceilings eastern Minnesota...elsewhere...visual flight rules.

IA

Ceilings overcast 1,500-2,500 feet. Tops 8,000-10,000 feet. Broken 15,000 feet. Tops FL200. Broken cirrus. 340 degrees 15 knots gusting 25 knots. Chance light snow mist mainly northeast Iowa...chance light rain mist elsewhere. Outlook...marginal visual flight rules.

IL

Northwestern Illinois...ceilings overcast 1,500 feet-2,500 feet. Tops 8,000 feet-10,000 feet. Broken 15,000 feet. Tops FL200. Broken cirrus. 340 degrees at 15 knots gusting 25 knots...chance light rain mist elsewhere. Outlook...marginal visual flight rules ceilings. Rest of Illinois...ceilings broken 5,000 feet broken 10,000 feet. Tops FL200. Broken cirrus. Becoming 1100-1700 ceilings broken-overcast 2,000-3,000 feet. Clouds layered to FL240. Broken cirrus. Widely scattered thunderstorms light rain showers/light rain showers developing. Cumulonimbus tops FL310. Outlook...marginal visual flight rules ceilings rain showers mist.

The North Central Area Forecast, issued at 1145, valid until 0200 for clouds/weather and 0200-0800 for the outlook.

MN

Arrowhead...ceiling broken-overcast 2,500 feet tops to 14,000 feet. Visibility 3-5 miles light snow blowing snow. Wind northerly gusting 30 knots through 0200. 1800 ceiling overcast 1,000 feet. Visibility 3 miles light snow blowing snow. Outlook...instrument flight rules ceiling snow. Remainder northern half...ceiling broken 3,000 feet tops to 12,000 feet. Visibility occasional 4-5 miles light snow blowing snow. Wind northerly gusting 25 knots.

IA

Ceilings overcast 1,500-2,500 feet. Tops 8,000-10,000 feet. Broken 15,000 feet. Tops FL200. Broken cirrus. 340 degrees 15 knots gusting 25 knots. Chance light snow mist mainly northeast Iowa...chance light rain mist elsewhere. Outlook...marginal visual flight rules ceilings.

IL

Northern half...ceiling overcast 1,500-2,000 feet tops to FL180. Visibility 3-5 miles light rain showers. Widely scattered thunderstorms light rain showers. Cumulonimbus tops FL350. Wind westerly gusting 25 knots. Becoming 2000 to 2300 ceiling overcast 1,500 feet tops to 15,00 feet. Widely scattered last rain showers east. Outlook...marginal visual flight rules ceiling. Southern half...ceiling broken 3,000 feet tops to 12,000 feet. Visibility occasional 3-5 miles light rain showers. Widely scattered thunderstorms light rain showers. Cumulonimbus tops FL400. Becoming 2000 to 2300 ceiling overcast 3,000 feet. Outlook...marginal flight rules ceiling.

In-Flight advisories (AIRMETs) included the following for icing:

AIRMET ZULU Update 1 was issued at 0245 for ice and freezing level.

AIRMET Ice...SD NE KS MN IA MO WI IL MI LS LM LH OK TX

From YQT to SSM to YVV to DXO to JOT to STL to SGF to ABI to INK to 50W LBL to ABR to BJI to YQT

Occasional moderate rime or mixed icing in cloud in precipitation below 15,000 feet. Conditions developing/spreading eastward during period...continuing beyond 0900 through 1500.

Freezing level...surface-4,000 feet northwest of OSW-ODI-SSM line rising rapidly to 10,000-12,000 feet southeast of line.

AIRMET ZULU Update 2, issued at 0845, for ice and freezing level valid until 1500.

AIRMET Ice...KS MN IA MO WI IL IN MI LS LM LH

From 110 ENE YQT to YVV to DXO to GIJ to 30N DYR to RZC to 50W OSW to MKC to MSP to DLH to YQY to 110 ENE YQT

Occasional moderate rime/mixed icing in cloud in precipitation between freezing level and FL180. Freezing level at or near surface northwest to 10,000 feet southeast. Conditions continuing beyond 1500 through 2100 and moving slowly southeastward.

Freezing level...surface-4,000 feet northwest of OSW-ODI-SSM line rising rapidly to 10,000-12,000 feet southwest of line.

AIRMET ZULU Update 3, issued at 1445, for ice and freezing level valid until 2100.

From YQT to YVV to DXO to FWA to 3CVG to BWG to MEM to LIT to 60SSE SGF to UIN to DLL to YQT

Occasional moderate rime/mixed icing in cloud in precipitation between freezing level and FL180. Freezing level at or near surface northwest

NTSB Probable Cause

The improper planning/decision by the pilot to fly into forecast icing conditions with an airplane not equipped with a certified deice system. The continued flight in known icing conditions and the flight to an alternate destination not performed by the pilot were additional causes. A contributing factor was the pilot's lack of qualification as an air carrier.