NTSB Factual Report

HISTORY OF FLIGHT

On September 13, 2007, about 0951 Pacific daylight time, a Beech A-36TC, N1811Q, impacted a tree growing out of a dense stand of brush and smaller trees about one and one-half mile northwest of the approach end of runway 10 at Skagit Regional Airport (Bayview), Burlington, Washington. The private pilot and his two passengers were killed in the accident, and the airplane, which was registered to Textana, Inc., was destroyed by the impact and post-crash fire. The 14 CFR Part 91 personal flight, which departed Havre, Montana, about four hours prior to the accident, was on an Instrument Flight Rules (IFR) flight plan. There was no report of an ELT activation.

At the time of the accident, the pilot was attempting a Global Positioning System (GPS) approach to runway 10 at Skagit Regional Airport. He attempted one previous approach, but had executed a missed approach procedure, and was making a second attempt. During the period of time that he was attempting the two approaches, the reported ceiling was 100 feet overcast, the visibility was one-quarter mile, and the temperature/dew point spread was zero degrees (12 degrees Celsius/12 degrees Celsius).

Shortly after the pilot's departure from Havre, he contacted Salt Lake Air Route Traffic Control Center (ARTCC), and was assigned an en route IFR altitude of 12,000 feet. About 45 minutes after his initial contact with Salt Lake Center, the pilot was assigned an altitude of 13,000 feet for terrain clearance. About one hour after being cleared to 13,000 feet, the pilot made contact with Seattle Flight Watch in order to get an update on the weather conditions at his planned destination. About one hour and ten minutes after being cleared to 13,000 feet, the flight was cleared to 12,000 feet, where it remained until the beginning of its terminal descent.

At 0908:16, while descending through 10,200 feet for 10,000 feet, the pilot contacted Whidbey Approach. He received the current altimeter setting, and then leveled at 10,000 feet.

At 0910:35, the controller asked the pilot if he had the current ASOS (Automated Surface Observing System) for "Skagit" yet, and the pilot responded with, "Yes sir I do, and it doesn't sound very good." The controller then asked the pilot to verify that his request was for the RNAV (GPS) approach for runway 10. The pilot confirmed that was his request, and the controller advised him that he should expect that approach.

At 0911:38, the controller cleared the pilot to descend to 6,000 feet, and after acknowledging the clearance, the pilot asked the controller, "If I can't get in here, where is the nearest airport with an ILS (Instrument Landing System)?" The controller advised the pilot that Bellingham was the nearest such airport, and the pilot responded with, "I'd like to get that as my alternate, I guess." The controller then told the pilot he would check to see what the weather was at Bellingham. About one minute later, the controller advised the pilot that Bellingham had not been able to "get anybody in yet" because they had zero visibility with zero vertical visibility. The pilot responded to that information with, "We got to pick some other place then, I guess."

The controller then asked the pilot if he was familiar with Boeing Field in Seattle, and the pilot responded that he was, and that he could go there. The controller then advised the pilot that Boeing Field had a visibility of three miles, and an overcast ceiling at 600 feet. The controller also advised the pilot that Paine Field (about 33 nautical miles southeast of Skagit Regional Airport) had one-quarter mile visibility and a 100-foot ceiling. He further advised the pilot that of everything around the area, the "best bet" was Boeing Field. The pilot responded to that information with, "Thank you sir. Let's just hope we can get in here."

At 0916:28, the controller advised the pilot to cross SOCLO (the Initial Approach Fix) at or above 4,000 feet, and then cleared him for the RNAV (GPS) approach to Runway 10. The pilot acknowledged the clearance, and then inquired of the controller whether he (the controller) would be able to hear his radio transmission on the ground at Skagit Regional, if he was able to get in there. The controller advised the pilot that sometimes he could hear radio transmissions from the airport, and then provided the pilot with a phone number to contract him on once he was on the ground. The pilot then advised the controller "If I get in, I will just give you a call on the land line (presumably to cancel his IFR clearance)." About one minute after the pilot advised the controller that he would call him on the ground, the controller queried the pilot as to whether his instruments showed he was going direct to SOLCO. The pilot responded that he was not presently going direct to SOLCO, but was instead intercepting the final approach course with the intention of flying that outbound. The controller then asked him if he would like vectors for a straight-in, but the pilot responded with, "No, that will be fine. I'll do the procedural turn."

About two minutes later, the controller advised the pilot that radar indicated he was "a couple of miles south of SOLCO," and then asked him if he was correcting to the north. The pilot responded that he was.

At 0923:33, the pilot reported that he was "established" and the controller told him that he "concurred." The controller then approved the pilot's change to "advisory frequency," and advised him to either report a missed approach or to call him from the ground.

Soon thereafter, an airport employee heard the pilot call Skagit Regional three times on the common traffic advisory frequency (CTAF). The employee, who reported that at the time the visibility was less than one-quarter mile, answered the call over the radio in the truck he was in. Since he got no response from the pilot, the employee transmitted again, asking if the pilot needed help. He received no response to that call either.

At the time the employee made the radio calls, he was in the truck on the taxiway that runs parallel to the runway, and he was driving toward the approach end of Runway 10. He reported that after making the radio calls, he saw the airplane just after it had flown past the VASI (Visual Approach Slope Indicator) for Runway 10. He said that when he saw the airplane "It was about 25 feet off the runway, and on the accent..." The airplane soon went out of sight in the low clouds, and the employee did not hear any other transmissions from the pilot.

At 0929:40, the pilot reestablished contact with Whidbey Approach, and soon thereafter advised the controller that he was "up on top," and that he would like vectors for the same approach again. The pilot then advised the controller that, "I got down to minimums, and could just see the runway, but I'd already started my missed approach." The controller then advised the pilot to, "…continue on the published missed approach procedure, and expect vectors to SLOCO leaving three thousand."

At 0933:00, the controller advised the pilot that he appeared to be "deviating from the missed approach." The pilot responded to that statement with, "I'm going direct to ISLND (the third waypoint of the missed approach track) at the present time." The controller's response to the pilot's statement was, "So you're going to ISLND right now?" The pilot then transmitted, "That's affirmative. I think it shows that I'm supposed to make a right hand turn and then back to ISLND." At that time the controller cleared the pilot to proceed direct to ISLND, and advised him to expect clearance from ISLND for the same approach he had shot the first time.

The controller then suggested to the pilot that if he got a chance, he might want to review the approach plate, and then further advised him that the published missed approach waypoint sequence was HOSVA, KIKYE, and then ISLAND. The pilot responded with, "I will sir. Thank you." The controller then also advised the pilot that during his missed approach he had gotten "…a little close to Devils Mountain."

At 0936:01, the controller cleared the pilot to cross SOCLO at 4,000 feet, and then cleared him for a second RNAV approach to Runway 10. At 0945:01 the pilot reported "established," and the controller approved the change to advisory control frequency. The controller then reminded the pilot to report his IFR cancellation once he was on the ground. The pilot's affirmative response to that reminder was the last known transmission from the airplane.

PILOT INFORMATION

The 59 year old pilot held a private pilot certificate with ratings for the operation of single engine aircraft and for operating under instrument flight rules (IFR). He had accumulated about 4,100 hours of total flying time, of which about 4,050 hours were in the make and model airplane he was flying at the time of the accident. His last FAA medical examination, a Third Class, was completed in October of 2005. The date of his last flight review was unable to be determined.

AIRPLANE INFORMATIOIN

According to personnel at Havre Flying Service, the entity that normally provided fuel for N1811Q, on the day before the accident flight, the pilot requested that the airplane's tip tanks be topped off. According to Havre Flying Service, after the tip tanks were topped off, all of the airplane's fuel tanks were full.

According to the airplane records, the last annual inspection was performed on November 13, 2006. On that date, the airframe had accumulated 4,201 hours, the engine had accumulated 1,485 hours, and the tachometer read 2,079.0 hours.

The last major change in navigational instruments occurred on December 31, 2002. At that time, a number of instruments were removed, to include a Collins ANS 351 RNAV, and an Apollo 2001 GPS. As part of that same maintenance action, a Garmin GNS 530 GPS and a GDL data-link receiver were installed. The Garmin GNS 530 GPS was certified for GPS navigation en route, terminal, and non-precision approach.

The last airframe maintenance entry occurred on February 21, 2007, and indicated that the right elevator trim tab hinge assembly was removed and replaced.

The last engine log entry, which was dated July, 23, 2007, indicated that the engine had been disassembled and inspected, and that the old crankcase was replaced with an overhauled unit. The same crankshaft was reinstalled, along with overhauled connecting rods, and an overhauled camshaft. The engine was reassembled using new rod and main bearings. No work was performed on the cylinders.

METEOROLOGICAL INFORMATION

The evening before the flight, the pilot contacted Denver Automated Flight Service Station in order to file a flight plan and to acquire the forecast winds aloft. At that time, the briefer asked the pilot if he would like the forecast adverse conditions, and the pilot advised the controller that he would get those the next morning.

On the morning of the flight, the pilot called the same FAA facility, and asked for a weather update, including the adverse conditions, and a terminal forecast for Burlington, Washington.

During that briefing, the pilot was advised that the current conditions at Burlington were winds calm, visibility of less than one-quarter mile, fog, a 100-foot overcast ceiling, with both temperature and dew point at 10 degrees Celsius.

The pilot was also given the current conditions for Bellingham, Washington and for Payne Field in Everett, Washington. The conditions for Bellingham were one-quarter mile visibility, fog, and a 100-foot ceiling. The conditions for Everett were a 100-foot overcast ceiling, one and three-quarter miles visibility,

The pilot was then given the current conditions for Whidbey Naval Air Station, which was indefinite 100 feet, a quarter mile visibility and fog. He was also advised that both Friday Harbor and Orcas Island were showing 100-foot overcast.

The pilot and the briefer then began discussing when the weather would start to clear, and the briefer advised him that Whidbey Island's weather would start to change between 1400 and 1600 ZULU (0700 to 0900 Pacific daylight time). And that after 1600 ZULU the Whidbey forecast was for 300 scattered, five miles visibility, and mist.

The briefer also advised him that by 1200 Zulu, the Bellingham weather would be changing to 100 scattered, occasionally 100 broken, with the broken ceiling occurring only up until "1000 mountain time" (0900 Pacific time).

The briefer then advised the pilot that, "By the time you get there, it should be clearing up,"

While the pilot was en route, at 1452Z (0752 Pacific daylight time), he contacted Seattle Flight Watch, and advised them he was north of Sandpoint, Idaho. He then asked for the current conditions at Burlington, and for the forecast conditions "… an hour and a half from now." Flight Watch then advised him that the current conditions at Bayview (Skagit Regional) were winds 160 degrees at three knots, visibility less than one-quarter mile, a ceiling of 100 feet overcast, with a temperature of 10 degrees Celsius and a dew point of 10 degrees Celsius.

The briefer also advised the pilot that there was "widespread IFR" west of the Cascades, and that it was supposed to burn off mid to late morning. He then advised the pilot that there was currently no terminal forecast for Bayview. In addition, he told the pilot that Friday Harbor's visibility was one-half mile and fog, Orcas Island visibility was less than one-quarter mile, and that the visibility at both Bellingham and Whidbey Island were one-quarter mile and fog. He further stated that, "Pretty much everybody is low IFR west of the Cascades."

The pilot then queried the briefer as to when the weather was supposed to burn off, and the briefer advised him that the terminal forecast was supposed to last until sometime between 1000 and noon, and that although some areas might "…burn off pretty quick," in other areas it, "…may be into the afternoon before the last of it burns off."

The pilot then thanked the briefer for the information, and stated that since he had departed Havre it had been, "…nice and clear."

The 1010 surface aviation weather observation (METAR) for Skagit Regional was winds calm, one-quarter statute mile visibility, an overcast ceiling at 100 feet, a temperature and dew point of 11 degrees Celsius, and an altimeter setting of 30.01 inches of mercury.

The previous five METAR's at Skagit Regional all indicated 100 foot overcast ceilings and visibilities of one-quarter statute mile, as did the next two METAR's taken at 1030 and 1050.

The 1110 METAR, which was taken about one hour and twenty minutes after the accident, indicated that the visibility had risen to one statute mile, but the overcast ceiling was still at 100 feet. The 1130 METAR, taken about 90 minutes after the accident, showed a visibility of four statute miles and an overcast ceiling of 200 feet. The 1150 METAR showed a visibility of 300 feet and an overcast ceiling of 400 feet.

RADAR DATA

According to the radar track plot provided by Whidbey Approach, during the second approach, when the airplane crossed SOCLO (the initial approach fix) its Mode C altitude was 4,000 feet mean sea level (MSL), which is above the published minimum crossing altitude for SOCLO of 3,900 feet. When the airplane was about half way between ENSEW and BRENN, at 48 degrees, 33.40 minutes North, 122 degrees, 36.05 minutes West, its mode C altitude was 3,000 feet MSL, which is above the published minimum approach segment altitude of 2,200 feet MSL. When the airplane was at 48 degrees, 32.22 minutes North, 122 degrees, 33.07 minutes West, approximately abeam BRENN, its mode C altitude was 2,700 feet MSL, which is above the published minimum crossing altitude at BRENN of 2,200 feet MSL. When the airplane crossed the mainland shoreline at 48 degrees, 29.97 minutes North, 122 degrees, 28.60 minutes West, its mode C altitude, which is transmitted in 100-foot increments, was 600 feet MSL. The last primary radar return, which occurred at 09:50:46, showed the airplane at 48 degrees, 29.50 minutes North, 122 degrees, 28.02 minutes West. Although the GPS Lateral Navigation (LNAV) Minimum Descent Altitude (MDA) at that location was

NTSB Probable Cause

The pilot's decision to descend below the published minimum descent altitude (MDA), and his failure to maintain clearance from vertical objects during an instrument approach. Contributing to the accident were low ceilings, inadequate preflight planning, and trees.