NTSB Factual Report

HISTORY OF FLIGHT

On August 30, 2016, about 1801 Pacific daylight time, a Beechcraft A-36 Bonanza airplane, N985CA, was destroyed when it impacted the ground in a recreational vehicle (RV) park about one-half mile prior to the threshold of runway 16L at Reno/Tahoe International Airport (RNO), Sparks, Nevada. The commercial pilot and passenger received fatal injuries, but there were no ground injuries. The airplane was registered to a private individual, and operated by Flying Start Aero, a flight school based at RNO. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed. The flight departed Henderson Executive Airport (HND), Las Vegas, Nevada, about 1600, and was destined for RNO.

According to one passenger who was on 3 of the flight legs that day, the plan was for the pilot to depart RNO with 2 passengers, pick up a third passenger in Las Vegas, Nevada, and continue on to southern California, where the 3 passengers were to attend a business meeting. Later that day, they planned to reverse that sequence, with the airplane, pilot, and 2 passengers returning to RNO in the late afternoon or early evening. All 3 passengers were employees of the same company, which was based near RNO.

According to the passenger, he and another passenger arrived at the Atlantic Aviation facility at RNO at 0350; the pilot was already there, and they proceeded to board the airplane. The flight departed RNO about 0410, and landed at Henderson Executive Airport (HND), Las Vegas, Nevada, sometime after 0600. That flight leg was smooth and uneventful.

HND fueling records indicated that the airplane took on 30 gallons of fuel sometime between 0624 and 0647. The airplane departed HND, and landed at French Valley Airport (F70), Murrieta/Temecula, California sometime after 0900. The 3 passengers then left the airport by car for their meeting and returned about 1300. The passenger did not know what the pilot did during the intervening hours.

The 3 passengers then re-boarded the airplane for the flight to HND. That trip leg was very bumpy. Prior to departure for the last leg of the flight to RNO, two of the passengers decided not to accompany the pilot and the third passenger on the flight back to RNO.

According to a flight instructor at Flying Start Aero, the pilot had telephoned sometime during the day to report that his passengers were running late, and that he would be returning to RNO later than originally planned. According to HND fueling records, the airplane was "topped off" with 24.3 gallons of fuel sometime between 1520 and 1530. Federal Aviation Administration (FAA) records indicate that the airplane took off from HND about 1600, and that the pilot requested and received flight following services for the visual flight rules flight.

The pilot first contacted the RNO air traffic control tower (ATCT) when the airplane was about 9 miles southeast of RNO. About 2 minutes later, the pilot reported that he was on downwind for runway 16L. About 2 minutes after that, the pilot was advised that his traffic was a Boeing 757 (B757) on a 9- mile final for runway 16R, was provided with the wind information, and was cleared to land. About 1 minute later, the pilot advised that he had "the airliner" in sight, and the accident airplane turned from westbound to southwest-bound, towards runway 16L. The pilot squared off the pattern once it got closer to the airport and turned onto the final approach leg to runway 16L about 1 mile from the runway threshold.

Multiple eyewitnesses reported that the airplane appeared to be approaching normally, without any unusual sounds or dynamics, or any smoke or other outward signs of distress. Just as the airplane was over the RV park, and at an altitude of less than 200 ft, it rapidly rolled and descended to the ground.

Ground scar and debris information was consistent with a near-vertical descent, in a near-vertical, nose down attitude. The airframe and engine incurred significant impact damage and were then further damaged or consumed by the post-impact fire.

PERSONNEL INFORMATION

Pilot

The 73-year-old pilot and his wife were the co-owners of Flying Start Aero, and the pilot was also the chief flight instructor. FAA information indicated that the pilot held commercial and flight instructor certificates with airplane single engine and instrument ratings. He reported a total flight experience of 11,100 hours on his most recent application for an FAA third-class medical certificate, which was issued in March 2016. The pilot's most recent flight review was completed in October 2014.

Pilot Logbook

Copies of the pilot's logbook were provided by the Flying Start Aero attorney. The most recent entry in the logbook was dated August 13, 2016. The logbook indicated that as of that date, the pilot had accrued a total flight experience of about 11,326 hours, all of which was in single engine airplanes. About 9,846 of those hours were logged as provision of flight instruction.

A review of the pilot's flight logbook back to August 2015 revealed 8 entries that were cataloged as something other than flight instruction. Six of those entries were conducted in a C-172, and the remarks included "scenic" for each of those entries. The entries did not contain any information regarding whether they were conducted in support of any charitable, non-profit, or community events, and did not indicate their range from the airport of origin. The other 2 entries, dated April 11-14, 2016 and June 12, 2016, were conducted in the accident airplane, and did not contain the "scenic" annotation in the remarks section. Both entries indicated that the flights originated and terminated at RNO, with a stop at an interim location. Neither of the interim landing locations were decipherable. The entries did not contain any information regarding whether they were conducted in support of any charitable, non-profit, or community events. The remarks for the April 11-14 flights appeared to state "visit Lin" but the remarks for the June 12 flight were not decipherable.

Pilot Schedule/Activity

According to the pilot's wife, the evening before the accident, he went to sleep about 2000, and awakened at 0330 the morning of the accident. She also reported that the pilot was "in good health" without any "significant related issues or problems."

According to Google Maps, the pilot's home was located a minimum driving distance of 6.3 miles from Flying Start Aero, with a drive time of about 17 minutes. The pilot's presence at the airport at 0350 was consistent with his leaving his home about 0330.

The direct distance from RNO to HND was 305 nm, and 174 nm from HND to F70, for a minimum total round-trip distance of 958 nm. Based on witness information, the flight time from RNO to HND was about 2 hours and 20 minutes, and from HND to F70, somewhat less than 2 hours. The investigation was unable to determine how or where the pilot spent the approximately 4 hours between his arrival at and departure from F70. The return trip leg duration from F70 to HND appeared to be about 2 hours. FAA air traffic control ATC information indicated that the return leg from HND to RNO was also about 2 hours.

Based on this information, the pilot's total flight time for the day was about 8.5 hours and included 4 takeoffs and 3 landings. The accident occurred about 14 hours after the flight's departure from RNO.

AIRCRAFT INFORMATION

General

FAA information indicated that the airplane was manufactured in 1981 and was equipped with a Continental Motors IO-550 series engine. Delivery documents indicate that the airplane was not equipped with a supplemental oxygen system. The airplane was owned by Venture Aviation Services of Reno Nevada and was placed on leaseback to Flying Start Aero in November 2014. The leaseback contract between the airplane owner and Flying Start Aero explicitly limited the airplane use to "commercial pilot flight training" and "rental to pilots approved by [the Flying Start Aero owner, who was also the accident pilot], as per insurance policy." The airplane owner told the investigator-in-charge that Flying Start Aero took very good care of the airplane, and did not defer any maintenance items.

Maintenance Records

The most recent annual inspection was completed in November 2015. According to the records for that inspection, the airplane had a total time (TT) in service of about 5,528 hours, the engine TT and time since overhaul (TSMOH) were about 998 hours, and the tachometer registered about 3,747 hours.

The only maintenance record entry subsequent to the 2015 annual inspection was for an oil and oil filter change in February 2016. At that time the airplane had a TT of 5,550 hours, the engine TT and TSMOH were about 1020 hours, and the tachometer registered about 3,769 hours. The investigation was unable to determine the airplane TT at the time of the accident.

METEOROLOGICAL INFORMATION

Observations and Reports

The 1755 RNO automated weather observation included wind from 290° (true) at 17 knots, gusting to 20 knots, visibility 10 miles, few clouds at 10,000 ft above ground level, temperature 31° C, dew point -5° C, and an altimeter setting of 30.01 inches of mercury.

About 1757:18, the RNO ATCT controller advised the pilot that the wind was from 260° (magnetic) at 13 knots, with gusts to 18 knots.

About 1758:53, the RNO ATCT controller advised "all aircraft" that automated terminal information service (ATIS) information "Kilo" was current, and that the wind was from 250° (magnetic) at 17 knots, with gusts to 20 knots.

Wind and Position Information for Bonanza N985CA

When the airplane was about 35 miles southeast of RNO, and about 17 minutes before the accident, the pilot confirmed to the NCT controller that he had RNO ATIS information "Juliet." Based on the available evidence, ATIS Juliet was likely based on the 1655 (PDT) METAR, which included wind of 230° (true) at 13 knots. The ATIS Juliet information prompted the pilot to respond that he wanted runway 25 when he was asked by the NCT controller. A wind from 230° (true, 216° magnetic) would have resulted in a 50° crosswind for a runway 16L landing.

At the time of the 1757:18 LC1 wind advisory (260° mag/13G18), the airplane was about 6.7 miles east-northeast of RNO, turning northwest, at an indicated altitude of about 7,900 ft.

At the time of the 1758:53 LC1 ATIS "Kilo" broadcast (250° mag/17G20), the airplane was about 3.5 miles northeast of RNO, on a wide, diagonal left base leg for runway 16L, at an indicated altitude of about 5,700 ft. From that location, if it turned about 50° to the left, the accident airplane could have entered a right base leg that would result in a 2 mile final for runway 25.

Sun Position

US National Oceanic and Atmospheric Administration data indicated that at RNO, about 3 minutes before the accident, the sun was at a true azimuth of about 267°, and an elevation about 17° above the theoretical horizon.

COMMUNICATIONS

General and RNO ATCT Staffing

Approaching RNO, the flight first communicated with Northern California Terminal Radar Approach Control (NCT), and then with the RNO ATCT local controller

A segment of the ATC recording was provided to a flight instructor at Flying Start Aero who knew the accident pilot well; he was asked whether he could identify the person on the radio in the accident airplane. It was his determination that the person on the radio was his colleague, the accident pilot.

According to the RNO ATCT personnel and position logs, at the time of the accident, there were 2 controllers on duty in the RNO ATCT. One controller was assigned to the local control position 1 (LC1) and the other was assigned to operational supervisor 1 (OS1) and ground control (GC) positions. Multiple position assignments for 1 individual during a work shift is normal operational practice.

The LC1 controller was the individual who communicated with the accident airplane from the time the pilot contacted the RNO ATCT until the accident. According to an NTSB interview the LC1 controller began working for the FAA in July 2010, and transferred to the RNO ATCT in May 2015. He was qualified on all operating positions within the ATCT and was designated a controller in charge (CIC).

The LC1 controller started his work shift at 1030, and ended it at 2300, for a total "on duty" time of 12 hours, 30 minutes. The Position Logs indicated that his "Position Duties" time was 5 hours, 16 minutes, and his "Non-Position Duties" time was 4 hours, 27 minutes.

After returning from his second break period, the controller was assigned to the LC1 position, and about 21 minutes later, the accident pilot made his initial contact with RNO ATCT, with the LC1 controller.

ATC Communications and Ground Track

About 1744, when the accident airplane was about 35 miles south-southeast of RNO, the pilot checked on with NorCal approach control (NCT) and advised the LC1 controller that he had RNO ATIS information Juliet. The LC1 controller asked for the pilot's runway preference, and the pilot stated that he wanted runway 25.

About 1751, the NCT controller issued a heading vector of 350°, and restricted the minimum altitude to 8,500 ft. The NCT controller advised the pilot to expect runway 25. At that time, the airplane's flight track was approximately perpendicular to, and about 7 miles east of, runway 25; this position and heading were consistent with a wide left base leg for runway 25.

About 1754, the NCT controller advised the pilot that there would be a "slight delay for runway 25," that he was "number four now for the airport," and advised that "traffic on a fifteen mile straight in is a Boeing seven fifty seven for one-six right." The pilot acknowledged, and advised the NCT controller that he could accept runway 16L. The NCT controller advised the pilot of N958CA to "proceed to the downwind" and contact RNO ATCT. The NCT controller did not specify which runway he was referring to, and the pilot did not ask or specify which runway that downwind assignment was for.

About 1754:33 the pilot contacted the RNO LC1 controller and transmitted "Reno tower good afternoon, Bonanza niner eight five charlie alpha restricted heading three-five-zero, eight thousand five hundred." About 1754:42, the NCT controller contacted the RNO LC1 controller via an interfacility landline to advise him that the pilot could accept runway 16L. The NCT controller stated that the airplane was being sent to "the downwind," but again the NCT controller did not specify which runway he was referring to, and the RNO LC1 controller did not ask or specify which runway that downwind assignment was for.

About 1754:50, the RNO local controller responded to the accident airplane pilot, and instructed the pilot to continue inbound for runway 25. The pilot acknowledged with the response "continue inbound for two five…". At that time, the airplane was at an altitude of about 8,600 ft, about 7.6 miles southeast of the runway 25 threshold. The airplane position and heading were consistent with it being on a left base leg for runway 25, about 3.5 miles south of a 6.5 mile final approach leg.

About 1755:08, an unidentified transmission consistent with those from the accident airplane queried "and ah tower, how about the restrictions?" The LC1 controller only partially heard this transmission, did not know which airplane it was from, did not acknowledge the communication, and did not request either a repeat or clarification of the transmission. The pilot did not repeat that transmission or transmit any related inquiries. Instead, the LC1 controller cleared a FedEx B757 to land on runway 16R and advised the FedEx pilots that their traffic was another B757 on a 5 mile final for the same runway. The LC1 controller never explicitly cancelled the NCT-assigned altitude and heading restriction, and never assigned any other heading or altitude to the accident airplane.

About 1756:20, the accident pilot reported that he was on a "wide downwind" for runway 16L, to which the RNO LC1 controller replied "Bonanza five charlie alpha roger continue inbound for one six left."

NTSB Probable Cause

The pilot's selection of a landing runway which, given the wind and traffic conditions, was susceptible to high crosswinds and the translation of wake turbulence across its approach path, and the controller's and pilot's failure to ensure separation from the B757 and its wake, which resulted in a low-altitude encounter with wake vortices that the pilot was unable to recover from.