NTSB Factual Report

HISTORY OF FLIGHT

On June 17, 1994, about 1055 central daylight time, a Beech A-36, N1525G, operated by the owner/pilot, impacted terrain in Brainerd, Minnesota, during a missed approach to runway 23. The airplane was destroyed. The certificated private pilot and two passengers were fatally injured. The remaining passenger was seriously injured. Instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed. The personal flight departed from Lincoln, Nebraska, at 0825 and was en route to Brainerd. The flight was conducted under 14 CFR 91.

According to FAA air traffic control (ATC) documentation, including transcripts of voice recordings and radar data (attached), the pilot received three preflight weather briefings by the Columbus Automated Flight Service Station (AFSS) on the morning of the accident prior to departure. The last briefing occurred at 0745. At 0819, the pilot was issued an IFR clearance from Lincoln to Brainerd. The pilot was cleared for takeoff at 0825. During the following two hours, the airplane flew at a cruising altitude of 9,000 feet mean sea level (msl) and was in communication with Lincoln ATC tower, Omaha Approach Control, Sioux City Approach Control, and finally, the Minneapolis Air Route Traffic Control Center (ARTCC). During this time period, the pilot twice requested and received approval to deviate from the intended course due to weather conditions. The pilot did not report any problems with the airplane.

At 1018, the Minneapolis ARTCC controller advised the pilot to plan for an Instrument Landing System (ILS) approach for runway 23 at the Crow Wing County Regional Airport in Brainerd. The pilot responded with "...thank you, I'll appreciate all the help I can get. I'm kind of new at this." The controller responded with "roger." At 1024, the pilot was issued a pilot's discretion descent to 6,000 feet msl. During the following 15 minutes, the pilot was cleared to descend to 4,000 feet msl and received vectors for the ILS Runway 23 approach.

At 1039:36, the controller advised the pilot to "... turn left heading two four zero to join the localizer." The pilot acknowledged. At 1040:49, the controller stated: "Two five golf I show you on the localizer nine miles northeast of the marker..." and cleared the flight for the approach. The pilot acknowledged.

According to a Recorded Radar Study performed by the Safety Board (attached), the airplane's flight path had just grazed the "full-fly-right" boundary of the localizer course. This boundary defines the region at which the needle on the airplane's localizer navigation instrument will begin to provide navigational guidance if the corresponding localizer frequency is selected. Immediately after grazing the boundary, the airplane began to fly away from the localizer toward the Brainerd Very High Frequency Omni-directional Range (VOR) transmitter.

At 1042:03, the pilot radioed "... I don't show myself on the course, where are you showing me?" The controller responded "... I show you a little left of course now, turn back right to a two seventy heading to join ..." The pilot acknowledged. The 270 degree vector issued by the controller was 40 degrees from the final approach course. The position of the airplane at the time of this communication was two nautical miles south of the full-fly-right boundary of the localizer.

During the following three minutes, the airplane turned to the left and penetrated the full-fly-right boundary of the localizer. During this time, the airplane descended from 3,500 feet msl to 2,700 feet msl. At 10:44:55, radar contact was lost and never regained; the airplane was located about 3 miles from the final approach fix.

At 1045:32, the controller asked the pilot, "... are you on the localizer now sir, or do you want to make a turn." The pilot did not respond.

About five minutes later, at 1050:11, the pilot contacted the controller and stated that he "... missed the approach, on a heading of zero six zero degrees at two thousand." The controller then instructed the pilot to climb and maintain 4,000 feet, and he asked the pilot if he would like to "... try the ILS on your own navigation or would you like me to give you a vector for it?" The pilot did not respond and was not heard from again.

The airplane was found about 1125 in a wooded area 2.79 nautical miles south of the airport.

In an interview, the surviving passenger stated that the pilot, the pilot's father, and the pilot's son wanted to fly to Brainerd for a weekend of fishing. The surviving passenger was a friend of the pilot; he stated that he was on the flight because he wanted to "pick up a ride" to his summer home in Brainerd.

The passenger was seated in an aft-facing seat on the left side of the cabin behind the pilot. The right front seat was occupied by the pilot's father, and the right rear seat, which was forward facing, was occupied by the pilot's son. The passenger stated that he was not wearing an intercom during the flight and could not hear conversations from the pilot; however, he could see and hear the pilot's son seated across from him.

The passenger stated that the flight departed from Lincoln, Nebraska on the morning of the accident after the pilot received a weather briefing and had the airplane "topped off" with fuel. The airplane was flown at a cruising altitude of 9,000 feet. During the flight, some turbulence was encountered as the airplane passed through "a couple of fronts," but the weather was "not violent" during the approach into the Brainerd area. Visibility, however, was poor, according to the passenger.

During the first approach to the airport, the passenger recalled flying parallel to a road after they had broken out of the clouds. He stated that the airport was nowhere in sight, so the pilot began to climb back up again. The passenger remembered maneuvering for a second approach to the airport that involved several "left turns." The pilot's son told the surviving passenger that they "were going down" and the passenger recalled telling him "its going to be alright." He said the airplane was "banked a little to the left" in a descent. The passenger then saw trees and something streaming out of the left wing just prior to impact. He characterized the time span from the missed approach to the impact as "short." After impacting terrain, the passenger walked to a farm house and telephoned local authorities.

The passenger stated that at no time did he perceive any indications of mechanical malfunctions with the engine or the airplane.

The accident occurred during the hours of daylight at 46 degrees, 22.60 minutes North and 94 degrees, 04.61 minutes West.

PERSONNEL INFORMATION

The pilot, age 45, was a certificated private pilot with a rating for single engine land airplanes. The pilot received an instrument rating on December 6, 1993. According to FAA records, the pilot was issued a FAA Second Class Medical Certificate on August 26, 1993, with no limitations. The pilot's logbook was not recovered. According to the pilot's FAA Airman Certificate and/or Rating application dated December 6, 1993, the pilot reported 140 hours of total flight time, including 61 hours in type and 47 hours of instrument instruction.

AIRCRAFT INFORMATION

The airplane, a 1988 Beech A-36, was co-owned by the pilot. He became a partner in the purchase of the airplane on June 8, 1994. The airplane was powered by a 300-horsepower Continental IO-550 engine and a controllable three-blade McCauley propeller. It had retractable landing gear and flaps. The airplane was also equipped with the following radio communications and navigational equipment:

- King KFC-150 2-axis Flight Control System - King KY-196A Communication Transceiver - King KNS-81 Navigation Transceiver with KI-525A Indicator - King KX-165-24 Communication/Navigation Transceiver with KI-202 Navigation Indicator - King KN-63 Distance Measuring Equipment (DME) Transceiver with

KDI-572 Indicator - King KMA-24 Audio Panel/Marker Beacon - King KR-87 Automatic Direction Finder (ADF) - King KT-79 Transponder

An examination of the airplane's engine and airframe logbooks did not reveal any unresolved discrepancies prior to departure on the day of the accident.

AERODROME INFORMATION

The Crow Wing County Regional Airport is uncontrolled. Runway 23 is served by an ILS. The ILS includes a localizer, glide slope, middle marker beacon, locator outer marker beacon, high intensity runway lights, and runway alignment indicator lights. Approaches into the airport are controlled by the Minneapolis ARTCC.

The entire ILS for runway 23 underwent a flight inspection by the FAA on the day of the accident. According to the Flight Inspection Report (attached) the facility operation was "found satisfactory."

According to the U.S. Terminal Procedures for the ILS Runway 23 approach (attached), the published decision height for the straight-in ILS approach is 1,424 feet msl (200 feet above ground level). The minimum visibility required is 1/2 mile. The published missed approach procedure is to "climb to 2000 [feet msl] then climbing right turn to 3000 [feet msl] direct [locator outer marker] and hold." The remains of a current copy of the U.S. Terminal Procedures for the ILS runway 23 approach was found in the wreckage.

METEOROLOGICAL INFORMATION

The following meteorological observations were reported at the Crow-Wing County Airport about the time of the accident: estimated cloud ceiling 500 feet above the ground (agl) broken, 1,800 feet agl overcast, visibility 3 miles with light rain showers and fog, temperature 61 degrees F, dewpoint 59 degrees F, wind calm.

WRECKAGE AND IMPACT INFORMATION

The airplane wreckage was examined at the accident site on the evening of the accident, June 17, 1993, and again on June 18, 1993. The wreckage distribution path was oriented along a magnetic bearing of about 360 degrees and was 210 feet in length.

Evidence of sheared trees was found about 210 feet from the final resting site of the wreckage. The trees were sheared off about four feet above the ground. Pieces of the left wing tip were found in the sheared trees. About 50 feet from the sheered trees, a ground scar measuring 20 feet in length was found. Portions of the nose landing gear assembly were found in the ground scar.

A freshly cut tree branch that measured 3 inches in diameter was found about 30 feet beyond the ground scar. The cut was clean and uniform along its surface. The left and right main landing gear, and nose gear tire were separated from the airplane and distributed along a path which led to the final resting site of the airplane. Evidence of fire was found along this path. The airplane was found upright and oriented on a magnetic bearing of about 060 degrees. An outboard section of its left wing had separated from the airplane and was lying adjacent to it.

Both wing fuel tanks and associated fuel lines were compromised. Evidence of a ground fire was found in the center of the wreckage. The entire instrument panel, all switches, throttle quadrant, and control columns were destroyed.

All primary and secondary flight control surfaces were accounted for at the accident site and were found within the dimensions of the airplane. No evidence was found to indicate a flight control deficiency. The leading edges of both wings of the airplane exhibited evidence of crush damage. The engine and propeller remained attached to each other, but were separated from the airframe and found near the empennage.

The exposed portion of the electrically-driven flap actuator was measured to be 1.75 inches in length. According to engineering data from the Beech Aircraft Company, the measurement corresponds to a fully retracted flap setting. The exposed portion of the elevator trim actuator was measured to be 0.50 inches. According to engineering data from Beech, the measurement corresponds to an elevator trim setting of 10 degrees tab up (nose-down trim).

The engine, a Continental model IO-550-B(6), was examined at the accident site. No pre-impact mechanical deficiencies were noted. Oil was found inside the engine; no contamination was noted. Evidence of fuel was found in the fuel flow distribution valve and the fuel line leading to it. The propeller could be rotated through 360 degrees of rotation. Crankshaft drive and valve train continuity was verified for all six cylinders during propeller rotation. Both of the magnetos produced a spark when rotated. The engine-driven vacuum pump was disassembled and inspected with no discrepancies found.

The three-blade McCauley metal propeller was examined. All three blades remained attached to the hub and exhibited evidence of chordwise scratching and prominent S-bending.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by Dr. R. D. Rottschafer, M.D., of the St. Joseph's Medical Center, Brainerd, Minnesota, on June 18, 1994. A toxicological analysis (attached) was performed on specimens taken from the pilot by the FAA Civil Aeromedical Institute, Oklahoma City, Oklahoma.

ADDITIONAL INFORMATION

The Minneapolis ARTCC was issued a "Waiver to 125NM Radar Vectoring Restrictions" by the FAA on May 13, 1994 (attached). The waiver allowed the ARTCC to vector aircraft to the final approach course at Brainerd with the use of a 175 nautical mile setting on the controller's radar display. The waiver allowed an increase in the display setting from 125 nautical miles to 175 nautical miles, as specified in the FAA ATC Handbook, FAA Order 7110.65D, paragraph 5-120d2 (attached). The resolution and accuracy of target locations projected onto a radar display set at 175 nautical miles is less than that of a radar display set at 125 nautical miles.

Paragraph 5-121 of the ATC Handbook (attached) also specifies that headings for final approach course interception provided by ATC must permit an intercept angle no greater than 30 degrees if the aircraft is 2 miles or more from the interception point to the approach gate.

The aircraft wreckage was released to Mr. Edward M. Fisk, Lake Elmo, Minnesota, on June 18, 1994. Mr. Fisk is representing the registered owner of the airplane.

NTSB Probable Cause

THE PILOT'S FAILURE TO FOLLOW THE PUBLISHED MISSED APPROACH PROCEDURE, AND HIS FAILURE TO OBTAIN AND/OR MAINTAIN ADEQUATE ALTITUDE TO AVOID COLLISION WITH THE TERRAIN. FACTORS IN THE ACCIDENT WERE: THE PILOT'S LACK OF INSTRUMENT FLYING EXPERIENCE, AND THE CONTROLLER'S FAILURE TO FOLLOW STANDARD PROCEDURES AND TO PROVIDE MORE COMPLETE AND HELPFUL GUIDANCE TO THE INEXPERIENCED PILOT DURING THE APPROACH.