NTSB Factual Report

**This report was modified on March 6, 2015. Please see the public docket for this accident to view the original report.**

HISTORY OF FLIGHT

On January 24, 2013, about 1345 central standard time, a Raytheon Aircraft Company (RAC) A-36 Bonanza, N980SS, impacted trees and terrain in a wooded area near Richwood, Louisiana, while on an instrument approach for landing at the Monroe Regional Airport (KMLU), Monroe, Louisiana. The commercial pilot and three passengers were fatally injured. The airplane was destroyed by the impact forces and a postcrash fire. The airplane was registered to, and operated per Central Flying Service, Inc., under the provisions of 14 Code of Federal Regulations Part 91, as a personal flight. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed and active. The flight originated from Beaumont Municipal Airport (KBMT), Beaumont, Texas, at 1225, and was destined for KMLU.

At 1331, the pilot of the airplane checked in with KMLU approach control and reported he was at 7,000 feet msl. Radar track data showed the airplane southwest of the airport on about a 035 degree heading.

At 1334:20, with the airplane approximately 37 miles from KMLU, the approach controller directed the pilot to turn left 15 degrees to join the localizer, to track the localizer course inbound, and to descend at the pilot's discretion to 2,000 feet msl. The pilot acknowledged. The airplane was sequenced to follow a King Air descending out of 12,000 feet. Radar showed the airplane at 7,000 feet msl and a groundspeed of 171 knots.

At 1338:48, the approach controller requested the pilot to report established on the localizer inbound. The pilot responded that he would report established on the localizer inbound. At 1339:25, the approach controller advised the pilot that it appeared that he had flown through the final approach course and was still northbound. The pilot responded that he was just seeing that and requested a radar vector to return back to the localizer course. The approach controller issued a right turn to a heading of 070 degrees. The pilot acknowledged the heading of 070 degrees. Radar showed the airplane at 5,700 feet msl on a heading of about 025 degrees and a groundspeed of 161 knots. The airplane then turned to the heading of 070 degrees.

At 1341:21, the approach controller queried the pilot if he was receiving the localizer signal. The pilot responded, "It's coming."

At 1342:26, the approach controller directed the pilot to contact tower, but then corrected himself and asked if the pilot was receiving the localizer. The pilot replied that he was established on the localizer and was "going over to tower." The approach controller responded that the airplane was four miles from the SABAR final approach fix, cleared for the ILS runway 4, and to contact tower on frequency 118.9 MHz. The pilot acknowledged that he was cleared for the approach and was switching to the tower frequency.

At 1344:18, the pilot checked in with KMLU tower for the ILS approach to runway 4. The tower local controller issued a landing clearance for runway 4. The pilot acknowledged that he was cleared to land runway 4 and that he was "curious that he was not going to be able to get down." The tower asked the pilot if he was going to be able to make the descent. The pilot responded that he was at 3,000 feet and it was as much as he could descend at the moment. The local tower controller advised the pilot to expect to receive vectors around for another ILS approach as there was another aircraft on the approach behind the airplane. The pilot did not respond.

At 1344:49, radar showed the airplane on a heading of 042 degrees, at 3,100 feet msl, and a groundspeed of 183 knots

At 1345:22, the tower local controller cancelled the airplane's landing clearance and directed the pilot to fly runway heading and maintain 2,000 feet. The pilot did not respond. Radar showed the airplane in a tight right, descending turn at 1,600 feet, and a groundspeed of 210 knots. Radar contact with the airplane was lost at 1345:36. At the time radar contact was lost, the airplane was at 1,200 feet and headed south-southwest away from the airport.

At 1345:32, the tower local controller asked the pilot if he was still on the localizer. The pilot did not respond. The tower local controller made several radio calls to the airplane without response. At 1346:09, the tower local controller transmitted to the airplane that radar contact was lost four miles south of the Monroe airport and queried the pilot if he was on the tower frequency. There were no further transmissions between the tower and the airplane.

A witness whose home was on the approach path to the airport heard the airplane go over his house. He went outside to see if he could see it, but didn't because the weather was overcast skies. He said he did hear the engine sound change as if the pilot reduced power and then put it back in again. Several witnesses near the accident site saw the airplane come out of the clouds descending almost vertically toward the ground at a high rate of speed. They lost sight of the airplane as it descended below the tree tops. They then heard sounds of the airplane impacting the trees and terrain.

PERSONNEL INFORMATION

The pilot, age 31, held a commercial pilot certificate for airplane single-engine land, multi-engine land, instrument airplane. He also held certificates as a flight instructor for airplane single-engine land and instrument airplane, and ground instructor, instrument. The pilot held a first class airman medical certificate issued May 13, 2008, with no limitations.

The pilot was hired by Central Flying Service, Inc. on April 16, 2012. According to information reported by the company to the FAA, as of July 25, 2012, the pilot had 470 total flying hours.

The company also reported that the pilot successfully completed company check rides on July 27, 2012, to be able to instruct in the company's airplanes.

According to information obtained by the FAA, the pilot had less than 10 hours in the accident airplane.

AIRCRAFT INFORMATION

The six seat, low-wing, retractable landing gear airplane, serial number E-3152 was put in service on February 22, 1998. It was powered by a Continental Motors, Incorporated, IO-550B-45B, 300 horsepower engine and equipped with a McCauley, part number D3A32C409-C, three-bladed constant speed propeller. A review of the airplane's maintenance records showed it underwent an annual inspection on January 9, 2013. The total airframe time at the annual inspection was 2,823.2 hours. According to the operator, the airplane flew about 10 hours after the annual inspection was performed, making the total time on the airframe at the time of the accident 2,833.2 hours.

The airplane's engine, serial number 834715R, was installed on August 27, 2007. The total time on the engine since major overhaul was 872.6 hours.

The propeller, serial number 971813, had a total time of 2,823.2 hours. It's time since major overhaul was 1,222.3 hours.

METEOROLOGICAL INFORMATION

At 1253, the recorded weather at KMLU was wind 060 degrees at 8 knots, visibility 1-1/2 statute miles in mist, sky condition overcast at 400 feet, temperature 13 degrees Celsius (C), dew point 11 degrees C, and altimeter 30.27 inches of Mercury.

At 1353, the recorded weather was wind 050 degrees at 12 knots, visibility 2 statute miles in mist, sky condition overcast at 700 feet, temperature 12 degrees C, dew point 9 degrees C, and altimeter 30.26 inches of Mercury.

AERODROME AND GROUND FACILITIES

Monroe Regional Airport, elevation 79 feet msl, is located about 4 miles east of the city of Monroe, Louisiana, at geographic coordinates: 32-degrees, 31 minutes north latitude, and 092-degrees, 02 minutes west longitude. The airport has three runways; runway 4-22, runway 14-32, and runway 18-36. Runway 4-22 is the longest at 7,505 feet and 150 feet wide. Runway 4 was the active runway the day of the accident. It has a standard A-5 approach end lighting system with sequenced flashers and high intensity runway lighting (HIRL).

The Instrument Landing System approach to runway 4 is a procedure turn approach with the non-maneuvering side to the southeast of the 222-degree radial. The inbound course is 042 degrees. The final approach fix, which is also the outer marker and glide slope intercept for the approach is SABAR. It is located 4.2 nautical miles from the runway threshold. The approach requires the pilot remain at 1,500 feet msl prior to SABAR, at which time, the pilot can fly the ILS glide slope to the approach decision height for landing of 276 feet msl, or descend to the minimum descent altitude (MDA) for the localizer approach of 540 feet msl. At an approach speed of 90 knots, an airplane should take 2 minutes and 48 seconds to reach the missed approach point.

The weather minimums needed to fly the ILS approach are a ceiling of 200 feet agl, and a visibility of 1/2 mile. To fly the localizer approach, the minimums are raised to a ceiling of 500 feet agl and visibility 1/2 mile for category A and B aircraft, and 1 mile for category C and D aircraft.

The published missed approach instructions for the approach require the pilot to maintain runway heading and climb to 1,800 feet msl, then make a right turn climbing to 3,000 feet msl, and then continue the right turn until proceeding direct to the Monroe VORTAC, where upon crossing it, the pilot will enter holding.

WRECKAGE AND IMPACT INFORMATION

The airplane impacted in a wooded area approximately 4.5 miles from KMLU on the 220-degree radial. The airplane wreckage was in the immediate vicinity of a 15 foot diameter impact crater that was approximately 8 feet deep. Trees in the immediate vicinity of the crater showed some broken branches. Small pieces of airplane debris were observed hanging from small braches of trees in the immediate vicinity of the crater.

Within the crater were the airplane's engine, propeller, nose gear, and cabin section. Crush angles and component positions within the crater were measured at a vertical impact angle of 100 degrees. The left and right wings were located outside the impact crater on the north and south rims. Both wings were broken aft at the wing roots and were crushed aft from the leading edge back to the aft spar, flaps and ailerons, along the entire spans. The left wing showed fire damage from the root to mid-span. The left main landing gear was folded in its wheel well. The right wing also showed fire damage from the root to the stall control device. The right main landing gear was broken aft.

The airplane's aft fuselage beginning at the baggage compartment, and the empennage rested on the northeast rim of the crater. The aft fuselage was crushed forward, bent and twisted. The empennage, to include the vertical stabilizer and rudder, and the left and right horizontal stabilizers and elevators were bent and crushed aft.

The airplane's cabin, forward fuselage and cowling were broken aft and fragmented, and portions were consumed by a postimpact fire. The airplane's engine was broken aft at the engine mounts and firewall. The airplane's propeller was broken at the flange. Bolt holes at the flange were elongated. Remaining flange bolts showed torsional fractures consistent with overload failures. The spinner was crushed and twisted aft. All three propeller blades were broken in the hub at their mounts. Two of the three blades showed torsional bending and chordwise scratches. The third blade was straight and broken aft at its mount in the hub. It showed chordwise scratches. One of the two blades showing torsional bending was also broken spanwise at the blade tip.

The airplane was recovered for further examination.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot on January 26, 2013 by the Ouachita Parish Coroner's Office, Monroe, Louisiana.

The FAA's Civil Aerospace Medical Institute performed forensic toxicology on specimens from the pilot showed the following volatile concentrations:

69 (mg/dL, mg/hg) Ethanol detected in Liver

42 (mg/dL, mg/hg) Ethanol detected in Muscle

12 (mg/dL, mg/hg) Ethanol detected in Kidney

10 (mg/dL, mg/hg) Ethanol detected in Lung

12 (mg/dL, mg/hg) Methanol detected in Liver

TESTS AND RESEARCH

The airplane wreckage was recovered to a hanger at MLU for examination. The examination, which took place on January 27, 2013, showed that all system components were fully functional at the time of the accident. Flight control cables and bellcranks showed numerous fractures and failures consistent with overload. Control continuity from the control yokes to the ailerons and elevators was confirmed. Control continuity from the rudder pedals to the rudder was also confirmed. Examination of the landing gear showed they were in the retracted position at impact. Examination of flight and engine instruments showed the airspeed indicator reading 242 knots indicated airspeed, altimeter showing 660 feet and the altimeter setting 30.26 inches, and the tachometer reading 550 RPM.

The airplane wreckage was relocated to Lancaster Texas. The wreckage, engine and several accessories were examined in detail on November 13, 2013. The engine examination revealed no preimpact anomalies. The engine oil filter and fuel distribution manifolds were disassembled and showed no anomalies. The dry air pump, which provides positive pressure air to the flight instruments was removed from its accessory and disassembled. The pump drive adapter showed no damage. The nylon pump adapter between the pump splines and the drive adapter showed a torsional twist in the shaft. No other anomalies were found with the airplane.

ADDITIONAL INFORMATION

Federal Aviation Regulations (FAR) Part 61, Certification, Pilots and Instructors, section 61.133 Commercial pilot privileges and limitations, states that a person who holds a commercial pilot certificate may act as the pilot in command of an aircraft (i) carrying persons or property for compensation or hire, provided the person is qualified in accordance with this part and with the applicable parts of this chapter that apply to the operation and, (ii) for compensation or hire, provided the person is qualified in accordance with this part and with the applicable parts of this chapter that apply to the operation.

FAR 61.23 Medical Certificates Requirement and duration, paragraph (a) Operations requiring a medical certificate states … a person --- (2) must hold at least a second-class medical certificate when exercising the privileges of a commercial pilot certificate;

The chart in paragraph d, Duration of a medical certificate, shows for a first-class medical certificate … on the date of examination for your most recent medical certificate you were any age, and you are conducting an operation requiring a commercial pilot certificate … then your medical certificate expires, for that operation, at the end of the last day of the 12th month after the month of the date of examination shown on the medical certificate.

NTSB Probable Cause

The pilot's failure to maintain control of the airplane during a missed approach in instrument meteorological conditions.