VFR into IMC · NTSB ERA09FA514

BEECH A36 — Flat Rock, NC

1 fatal High-time pilotIMCBase-to-final turn
DateSeptember 10, 2009
LocationFlat Rock, NC
AircraftBEECH A36
Purpose of flightPersonal
ConditionsDay · Instrument Meteorological Cond
Phase / occurrenceApproach-VFR pattern final Controlled flight into terr/obj (CFIT)
Pilot age65
Pilot total time2,220 hrs · Experienced
Time in typeUnknown
Fatalities1

Probable cause

The pilot’s attempt to maintain visual flight during instrument meteorological conditions, resulting in controlled flight into mountainous terrain. Contributing to the accident was the pilot’s failure to advise the controller of the weather conditions encountered, and his failure to request minimum safe altitude warning (MSAW) monitoring before departure.

NTSB findings

  • Environmental issues-Operating environment-Air traffic/operating proc-(general)-Not specified
  • Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Low ceiling-Contributed to outcome
  • Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Low visibility-Contributed to outcome
  • Personnel issues-Action/decision-Action-Incorrect action performance-Pilot - C
  • Personnel issues-Task performance-Planning/preparation-(general)-Pilot - F
  • Personnel issues-Task performance-Communication (personnel)-Lack of communication-Pilot - F

What happened

Although the pilot was instrument rated, the investigation found no record that his rating was current. The pilot advised the air traffic controller before departure that he did not want to execute any instrument landing system (ILS) approaches even though they were in use at the time, and neither transceiver was configured to the localizer frequency. Due to the mountainous terrain surrounding the airport, local air traffic control (ATC) had designated certain mode 3 transponder codes that inhibit minimum safe altitude warning (MSAW) processing for a controller. This was accomplished to prevent repeated nuisance alarms for aircraft operating under visual flight rules (VFR) and not requesting MSAW processing. The pilot did not request MSAW monitoring before departure or at any time during the flight; therefore, the assigned VFR transponder code (0210) inhibited the MSAW. The pilot departed the flight with a reported ceiling of 1,500 feet and 10 miles visibility before proceeding south of the departure airport and electing to return, remaining in constant contact with ATC. While operating only several hundred feet above mountainous terrain, in instrument flight rules conditions due to fog, the pilot did not advise the controller of the weather encountered. While being vectored towards the airport, the airplane impacted trees then terrain at an elevation of approximately 2,809 feet mean sea level. The pilot made no distress call and the controller did not provide a MSAW warning to the pilot. Postaccident examination of the airplane, engine, and engine systems revealed no evidence of preimpact failure or malfunction. While testing of avionics revealed that the “Trim” light bulbs of the autopilot remote mode annunciator and the autopilot and flight director computer were illuminated at the moment of impact, the left pitch trim actuator was found in the neutral position and the circumstances of the accident do not support a pitch trim malfunction. Additionally, the autopilot was not activated at the moment of impact.

An editorial "what led to it / how to avoid it" analysis for this accident is generated separately and will appear here.

View the official NTSB docket →