NTSB Factual Report

HISTORY OF FLIGHT

On October 23, 2004, at 0945 eastern daylight time, a Beech Bonanza F33A, N18303, registered to Air Equipment Inc. and operated by a private pilot, collided with the ground in the vicinity of Flat Rock, North Carolina. The personal flight was conducted under the provisions of Title 14 CFR Part 91 with an instrument flight plan filed. Instrument meteorological conditions prevailed at the time of the accident. The flight originated from Hendersonville Airport, Hendersonville, North Carolina, on October 23, 2004 at 0938.

At 0839, the pilot telephoned the Raleigh Automated Flight Service Station and requested a weather briefing from Hendersonville, North Carolina to Portsmouth, Virginia. After the weather information was given to the pilot he filed an instrument flight plan.

At 0938, the pilot was cleared for departure, and at 0942 radar contact was established with the airplane, and the pilot was instructed to turn left direct Sugarloaf VOR. After failing to respond to several calls, the pilot's reply transmission to the inquiry about his altitude cut out after "three thou". The pilot was instructed to climb at a good rate through 5500 feet. At 0945 radar contact was lost with the airplane.

According to witnesses the pilot waited at Hendersonville Airport for approximately one hour for improved weather conditions before departing. Witnesses estimated the weather to be 200-300 feet overcast with 1 1/2 miles visibility in fog. The witnesses observed as the airplane departed southeast on runway 14, climb out, and leveled off above the treetops under the cloud layer. Shortly after a radio call was heard from the Asheville approach stating "radar contact". Approximately 10 minutes later Asheville approach called the airport and asked if the airplane had returned to the airport because radar contact had been lost.

A witness near the accident site reported hearing an airplane "rev-up and idle down 3-times". The airplane sounded like it was making circles". First responders to the accident site reported foggy conditions at the time and location of the accident. The downed airplane was located in a ravine at the base of a hill in a nose down attitude.

PILOT INFORMATION

Review of the pilot's flight records revealed, he was issued a private pilot certificate on March 23, 2004, with airplane single- engine land and an instrument rating. Review of the pilot's logbook revealed he had a total flight time of 255 hours, and 35 flight hours in model and make. The private pilot held a third class medical certificate dated January 22, 2003, with no restrictions. Review of the private pilots logbook revealed that the pilot had 2.5 flight hours of actual instrument time, 59.7 flight hours of simulated instrument time, and the last instrument proficiency check was completed on October 14, 2004.

AIRCRAFT INFORMATION

Review of aircraft maintenance logbooks revealed that the last recorded altimeter, static, and transponder system checks were completed on July 2, 2004. The last annual inspection was conducted on July 02, 2004. The tachometer time, and total aircraft time at the annual inspection was 2915.7 hours.

METEOROLOGICAL INFORMATION

The weather forecast for Asheville effective at 1045 eastern daylight time, forecasted wind 140 degrees at five knots, visibility two statue miles, mist, ceiling seven hundred feet overcast, temperature 12 degrees Celsius, dew point 10 degrees Celsius, and an altimeter setting 30.20.

WRECKAGE EXAMINATION

Examination of the wreckage site revealed the airplane rested approximately four miles east from the Hendersonville Airport, at the base of a hill. All flight control surfaces, flight controls, engine and propeller were located at the site. The engine assembly was located at the base of a 6-foot crater with the propellers still attached at the hub. The propellers displayed chord-wise scoring, and the blades were bent aft. The left and right wing assemblies were attached to the fuselage. The cockpit and empennage was crushed damaged. The vertical and horizontal flight surfaces and controls were crush damaged.

Post accident examination of the airframe revealed, the main fuselage, and cockpit section of the airplane was crushed, and broken. All flight control, navigational instruments, and radios were crushed.

Post accident examination of the left wing assembly displayed accordion crush damage to the skin of the leading edge of the wing. The left wing assembly was crush damaged, and fragmented. The left aileron flight control cables were traced throughout the airframe to the cockpit flight controls. Flight control cable ends were attached to the aileron attachment fittings. The flap was attached and in the retracted position. The left main landing gear was in the down position.

Post accident examination of the right wing assembly displayed accordion crush damage to the skin of the leading edge of the wing. The right wing assembly was crush damaged. The right aileron flight control cables were traced throughout the airframe to the cockpit flight controls. Flight control cable ends were attached to the aileron attachment fittings. The flap was attached and in the retracted position. The right main landing gear was in the down position.

Post accident examination of the vertical and horizontal stabilizer revealed the left and right horizontal stabilizer was buckle and the elevator was buckled. Examination of the vertical stabilizer and rudder revealed it they were buckled. Post examination of the airframe did not reveal any flight control anomalies.

Post accident examination of the engine revealed the engine was intact with all external accessories attached except both magnetos, which were hanging, by the ignition leads. The number three cylinder was damaged. The aft exhaust pipes were separated, and the oil sump was crushed. The crankshaft was rotated and valve train movement was confirmed to all of the cylinders and to the oil pump, and all pistons were moving. The oil filter was crushed. The oil filter element was opened and no metal particles were observed in the element. The propeller governor was displaced to the rear, and separated from the engine case. The propeller governor drive coupling was separated, and the outer case was crushed with actuating arm separated.

Post accident examination of the fuel manifold revealed that it was crush damaged. The fuel screen was clean and clear. The fuel metering unit screen was clean and clear. Examination of the fuel pump revealed that the pump was attached the engine. The drive coupling was not damaged, and the drive shaft was free to rotate. The unit was disassembled and no internal damaged was observed.

Post accident examination of the magnetos revealed the right magneto was damaged and when rotated produced spark at all terminals. The left magneto was damaged and the points and condenser was crushed.

Post accident examination of the vacuum pump revealed that the pump was intact and damaged. The drive coupling was not damage, and rotated. The unit was dissembled and no internal damage was observed, and all rotor vanes were in place.

Post accident examination of the propeller revealed that it was still attached to the spinner. Both Blades exhibited bending and twisting on the propeller assembly. All blades had varying degrees of lead edge damage and rotational scoring.

PATHOLOGICAL INFORMATION

The Office of the Chief Medical Examiner, Chapel Hill, North Carolina preformed the postmortem examination of the private pilot on October 26, 2004. The reported cause of death was blunt force trauma. The postmortem toxicology specimens from the pilot were negative for carbon monoxide, cyanide, drugs and alcohol.

ADDITIONAL INFORMATION

The wreckage of the airplane was released to Leading Edge Investigations on August 8, 2005.

From Advisory Circular 61-23C (Pilot's Handbook of Aeronautical Knowledge), revised 1997: Chapter 9 - Spatial Disorientation and Illusions in Flight Many different illusions can be experienced in flight. Some can lead to spatial disorientation. Others can lead to landing errors. Illusions rank among the most common factors cited as contributing to fatal aircraft accidents. Various complex motions and forces and certain visual scenes encountered in flight can create illusions of motion and position. Spatial disorientation from these illusions can be prevented only by visual reference to reliable, fixed points on the ground or to flight instruments. The most overwhelming of all illusions in flight may be prevented by not making sudden, extreme head movements, particularly while making prolonged constant-rate turns under instrument flight rule instrument conditions.

NTSB Probable Cause

The pilot experienced spatial disorientation, which resulted in a loss of control and the subsequent collision with the ground. Factors were low ceilings and fog.