NTSB Factual Report

**This report was modified on August 31, 2016. Please see the docket for this accident to view the original report.**

HISTORY OF FLIGHT

On September 7, 2015, about 1203 eastern daylight time, N36HT, a Beech A36, was destroyed when it impacted terrain near Kernersville, North Carolina. The private pilot and the two passengers were fatally injured. The airplane was registered to Central Penn Aviation Academy Inc., Paxinos, Pennsylvania and operated by the pilot. An instrument flight rules (IFR) flight plan was filed for the flight that departed Sarasota-Bradenton International Airport (SRQ), Sarasota, Florida, about 0819, under the provisions of a 14 Code of Federal Regulations Part 91 personal flight. Instrument meteorological conditions (IMC) prevailed at the time of the accident.

According to radar and voice communication data provided by the Federal Aviation Administration (FAA), the airplane was being radar vectored by air traffic control for the ILS RWY 5R instrument approach to the Piedmont Triad International Airport (GSO), Greensboro, North Carolina, following a previous unsuccessful ILS approach to the same runway.

The pilot contacted GSO approach at 1132:54 and reported that he was descending through 5,700 ft. A controller replied that automated terminal information system (ATIS) information Delta was current, the altimeter setting was 30.19, and the pilot should expect to land on runway 5R. The pilot read back the runway assignment, and then asked if he should expect a visual approach. The controller stated that the pilot should expect the ILS approach, and asked the pilot to report when he had received information Delta. The pilot confirmed that he had information Delta, and then asked if the assigned runway was 5L. The controller reconfirmed the original assignment, runway 5R.

At 1133:51, the pilot asked the controller to confirm that he was cleared to descend to 5,000 ft. The controller responded that if 5,000 was the altitude assigned by the previous controller, it was correct, and also noted that he had not issued any other altitude instructions. The pilot acknowledged.

At 1135:14, the pilot again asked the controller to confirm whether he should expect runway 5R or 5L.The controller responded, "The right side – R I G H T." The pilot read back, "Five right 36HT."

At 1140:44, the controller instructed the pilot of N36HT to fly heading 360 for sequencing into GSO, and the pilot acknowledged. At 1143:26, the controller instructed the pilot to contact another controller on frequency 124.35.

The pilot contacted the controller at 1144:00 while the airplane was level at 5,000 ft. The controller provided the GSO altimeter setting, 30.19. At 1145:24, the controller cleared the pilot to descend to 3,000 ft. At 1148:01, the controller advised the pilot of potentially conflicting traffic ahead, type and altitude unknown. The pilot responded, "Roger – 36HT is about to go IMC." The airplane was descending through 3,600 ft at the time.

At 1148:38, the controller advised the pilot that traffic was no longer a factor and instructed him to turn right heading 010 degrees. The pilot correctly read back the heading. At 1149:04, the pilot reported level at 3,000 ft, and then asked if the controller wanted him to remain at 3,000 ft. The controller responded, "Affirmative."

At 1150:35, the controller transmitted, "N36HT niner miles from Pagan, turn right heading 020, maintain 3,000 until established on the localizer, cleared ILS runway 5R approach. The pilot responded, "Turning right heading 020 for Pagan." The controller restated the altitude restriction and the approach clearance, and the pilot correctly read it back.

At 1152:48, the pilot asked, "How do you like this route of flight?" The controller responded, "You look just a little bit right of course for the ILS, turn left heading 0…make that 360 for the ILS, report established." The pilot then asked, "Turning left or turning right for 360?" The controller replied, "left to 360," and the pilot acknowledged.

At 1153:59, the controller asked the pilot, "…are you established? [on the localizer]" The pilot responded, "Established if I could have vectors to final, please." The controller then asked, "…Are you established on the localizer?" The pilot stated, "I believe I am, 36HT." The controller continued, "Now you look like you just actually went through the localizer." The pilot replied, "Roger – request a vector for final for 36HT." The controller issued an instruction to another airplane, then at 1154:30 transmitted, "N36HT cancel your clearance, maintain 3,000, turn left heading 320 for sequencing." The pilot read back, "Left 320."

At 1156:42, the controller instructed the pilot to turn left heading 230 degrees for vectors to the ILS runway 5R approach. The pilot correctly read back the instruction.

At 1157:30, the controller asked the pilot to verify that he was flying heading 230. The pilot replied, "Negative, and 36HT is close to..." The transmission ended incomplete. The controller then took a coordination call from another facility. During that call, the pilot called again in a strained tone, stating, "N36HT request vectors," and the controller also noticed that the airplane's altitude was below 3,000 ft. He ended the call and at 1157:57 responded to the pilot, "Bonanza 36HT you need to be level at 3,000, altitude shows you 2,500, Greensboro altimeter 30.19." The pilot responded, "6HT climbing to three." The controller asked the pilot to verify that he was on a 230 heading. The pilot did not respond.

At 1158:40, the controller asked the pilot to verify the airplane was at 2,900 ft. The pilot did so. At 1159:16, the controller asked the pilot to verify the airplane's heading. The pilot responded that the airplane was heading 166. The pilot continued, "We need a descent, we are almost disoriented, N36HT…2,700." In the background of the transmission, a female voice said, "Turn something off."

At 1159:43, the controller instructed the pilot to start a left turn and 16 seconds later told him to maintain 2,500 ft. The pilot did not acknowledge the turn, but radar data indicated the pilot initiated a left turn. At 1200:16, the controller instructed the pilot to start a right turn. The pilot responded, "Right turn, 36HT leveling off 2,500." At 1200:47, the controller transmitted a low altitude alert to N36HT along with the altimeter setting, and asked the pilot to say altitude. The pilot did not acknowledge the transmission, and radar data showed that during the next minute the airplane initially turned right but then entered and completed a 360-degree left turn.

At 1201:25, the controller transmitted, "N36HT climb and maintain 4,000, I can see if I get you back up into the uh above the clouds." At 1201:35, the controller continued, "N36HT Greensboro approach you up? Last altitude showed 2,100." At 1201:41, the pilot transmitted "N36HT" in an agitated voice. The controller replied, "N36HT just climb and maintain 4,000, I'll block altitude for you."

At 1202:06, the controller asked the pilot of N36HT, "… if he was able to take the climb", and continued, "Last tops were reported at 3,500, if I can get you up to 4,000 maybe you can square it back off." At 1202:18 a short sound was heard, possibly from the pilot. At 1202:39, the controller advised the pilot that his altitude was 2,100 ft.

At 1202:44, an unidentified transmission of what sounded like breathing was heard on the frequency. At 1202:54, the pilot asked, "Is there a nearby field for 36 ho-." The controller responded, "…the nearest airport is Greensboro airport, off your left wing and off your current heading 7 miles. Right now showing 1000 overcast for the ceiling."

At 1203:21, the controller asked the pilot for his altitude. At 1203:34, screams were heard on the frequency. There were no further communications with the pilot.

Several witnesses observed the airplane just prior to the accident. One witness stated that when he first saw the airplane, it was "very low" in the sky and was in a "sharp left turn" toward the west. He said the airplane was banking so sharply that the wings appeared to be vertical to the ground. A second witness stated that the airplane was flying low and was beneath the "low clouds." She said the airplane, "...looked as if it were a trick plane practicing stunts or else someone trying to stabilize the plane but continuing to overcorrect as the nose would go down then up and the wings would go from right to left and back, but it never stabilized." She also said the airplane was going "very slow." She last saw the airplane descend behind a tree line and out of her view, but she could still hear its engine. She described the sound being similar to when a lawn mower engine "quits right before it runs out of gas." She said the engine revved up and then slowed, revved up and slowed, and then about 5 to 10 seconds later she heard a loud pop similar to a bottle rocket.

A third witness was in his front yard when he saw the airplane flying from right to left away from the airport. He said the airplane appeared to be flying normally and the engine was operating as if "everything was normal." A few minutes later the airplane turned back toward the airport. The witness said that before the airplane's wings leveled, the left wing dropped, followed by the right wing in a swaying motion. The witness said that as the right wing was coming back up to level, the airplane descended below the tree line and disappeared from view followed by the sound of an impact.

A fourth witness was in her front yard when she observed the airplane in a "severe" bank to the right heading toward the southeast. She said the airplane made a sharp right turn and "spiraled downward making 3 to 4 rotations" before it disappeared from view behind trees. Shortly after, the witness observed black smoke coming up from behind the trees where she last saw the airplane.

PILOT INFORMATION

The pilot held a private pilot certificate with ratings for airplane single-engine land, and instrument airplane. His last FAA third-class medical was issued on April 17, 2014. At that time, he reported a total flight experience of 750 flight hours. The pilot's most recent logbook was not recovered and his overall flight experience and currency were not confirmed.

The pilot resided in Pennsylvania and had flown down to Florida on September 4, 2015, with his wife, father-in-law, and a friend, who was also a pilot and owned a Beech A36. According to the friend, the pilot had recently purchased the airplane and wanted to have another pilot along since this was his first long flight in the airplane. The friend estimated that the pilot only had about 6 hours of flight time in the airplane before the flight. The friend said the flight to Florida was uneventful; the airplane flew well, and the weather was mostly visual flight rules (VFR). The airplane was equipped with a Garmin 530/430 GPS, autopilot and a flight director, which were new to the pilot. During the flight, the friend helped the pilot practice loading instrument approaches into the Garmin 530 and they executed a practice instrument approach. The friend said the pilot had a lot of flight experience in instrument conditions in a Piper PA-28-180 airplane, but it did not have the advanced avionics or autopilot like the A36. The friend added that the pilot was getting more comfortable with the Garmin 530 and autopilot by the time they arrived in Florida.

The friend said the pilot dropped him off in Sarasota, Florida, and then the pilot and his family flew to St. Petersburg, Florida, to visit their daughter/granddaughter. The friend did not plan to return to Pennsylvania with the family the following Monday, but did monitor their trip via FlightAware. The friend was not aware if there was any reason the family had to get home on the day of the accident.

According to the pilot's primary flight instructor, the pilot had accrued over 800 hours of total flight time and had a lot of IFR experience in a Piper PA-28-180 airplane. The instructor said he had flown IFR with the pilot in the past and felt he was "very good and conscientious." After the pilot had purchased the accident airplane in August 2015, the instructor gave the pilot a complex check-out (6 hours flight time, 1.5 hours ground), which also included a demonstration on how to use the Garmin 530 for instrument approaches. These approaches were all done in VFR conditions and the pilot was not "under the hood." After the check-out, which was completed on September 2, 2015, 5 days before the accident, the instructor was not sure if the pilot flew the airplane before going to Florida; however, he did tell him not to fly in actual IFR conditions until he gained more flight experience.

The instructor said that the pilot had invited him and his wife to fly with them to Florida, but the instructor was unable to take the time off for vacation. So the pilot asked another friend to go. The instructor mentioned that the family was returning home on the 7th because the pilot's father-in-law was having surgery the following day. However, a family member confirmed that was not the case and it was just a standard doctor's appointment.

AIRCRAFT INFORMATION

The six-seat, low-wing, single-engine airplane was equipped with a six-cylinder, horizontally opposed, fuel-injected, 285-horsepower Continental IO-520-BB engine (s/n 830171-R) that drove a three-bladed McCauley propeller (s/n EE3711B). The airplane's last annual inspection was conducted on March 6, 2015, at an airframe total time of 3,743 hours. The engine had accrued 326 hours since factory rebuild.

METEROLOGICAL INFORMATION

Weather reported at GSO, about 6 miles northeast of the accident site, at 1154, was wind from 090 degrees at 6 knots, visibility 10 statute miles, ceiling 1,100 overcast, temperature 23 degrees C, dewpoint 21 degrees C, and a barometric pressure setting of 30.19 in Hg.

According to Lockheed Martin, the pilot received two separate weather briefings through the automated flight service station (AFSS) system. The first telephone briefing was obtained before departing St. Petersburg and the other before departing Sarasota. The first briefing lasted about 3 minutes and 36 seconds. The pilot filed an IFR flight plan and reported the flight to Sarasota would take 15 minutes and he had 5 hours of fuel onboard. He requested a hazardous weather briefing and was informed that a convective SIGMET for embedded thunderstorms would be west along his route of flight. The pilot then interrupted the briefer and ended the briefing.

In Sarasota, the pilot again contacted AFSS and filed an IFR flight plan direct to GSO and asked for a hazardous weather briefing. The pilot said the flight would take 3 hrs and 30 minutes and he had 5 hours of fuel onboard. The briefer informed the pilot that an AIRMET for IFR weather was issued for northern and Central Florida, Georgia, South Carolina and North Carolina. The pilot then asked about the convective weather that was approaching Sarasota and was told that the leading edge of the storm was about 12.2 miles southwest of the Sarasota airport. The pilot then tried to end the briefing so he could leave before the storm, but the briefer said he had yet to provide the adverse weather information for the requested route of flight and would not be able to consider the briefing complete. The briefer also stated that he could get in trouble for not providing the weather that the pilot had requested from him, but would end the briefing if the pilot wanted to "cut him off." The pilot told the briefer to continue, but shortly after, interrupted him and said, "Ok, I am perfect. Thank you for all the help."

COMMUNICATIONS

As part of the investigation, an NTSB air traffic control specialist conducted interviews of the controllers with GSO approach control, which included the controller who worked south-radar, west-radar, and their front line manager. The south-radar controller and the west-radar controller were both in contact with the pilot. The south-radar controller, who first handled the accident airplane as it approached GSO, said he did not think there was anything unusu

NTSB Probable Cause

The pilot's loss of airplane control due to spatial disorientation, which resulted in an aerodynamic stall/spin. Contributing to the accident was deficient Federal Aviation Administration air traffic control training on recognition and handling of emergencies, which led to incorrect controller actions that likely aggravated the pilot's spatial disorientation.