NTSB Identification: BFO94FA103.
The docket is stored in the Docket Management System (DMS). Please contact Records Management Division
Accident occurred Friday, June 17, 1994 in BRAINERD, MN
Probable Cause Approval Date: 10/31/1995
Aircraft: BEECH A-36, registration: N1525G
Injuries: 3 Fatal,1 Serious.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

THE AIRPLANE WAS ON AN IFR FLIGHT PLAN. PRIOR TO THE APPROACH, THE PILOT TOLD ATC THAT HE 'NEEDED ALL THE HELP I CAN GET. I'M KIND OF NEW AT THIS.' HE WAS THEN CLEARED TO DESCEND AND BEGAN RECEIVING RADAR VECTORS FOR THE ILS APPROACH. THE AIRPLANE BEGAN TO HEAD TOWARDS A NEARBY VOR AFTER BEING VECTORED TO THE LOCALIZER COURSE. THE PILOT RADIOED THAT HE WAS NOT ON THE LOCALIZER AND REQUESTED ASSISTANCE. ATC PROVIDED ANOTHER VECTOR AND CLEARED THE AIRPLANE FOR THE APPROACH. THE AIRPLANE INTERCEPTED THE LOCALIZER AND THEN DISAPPEARED FROM RADAR. RADIO COMMUNICATION WAS LOST AFTER THE PILOT DECLARED A MISSED APPROACH. THE AIRPLANE IMPACTED TERRAIN SOUTH OF THE AIRPORT. THE PILOT HAD RECEIVED HIS INSTRUMENT RATING 6 MONTHS BEFORE THE ACCIDENT. SEVERAL PROCEDURES SPECIFIED IN THE ATC HANDBOOK WERE NOT FOLLOWED BY THE CONTROLLER. AFTER THE PILOT INITIALLY BEGAN TO STRAY FROM THE LOCALIZER COURSE, HE WAS NOT INFORMED OF HIS POSITION RELATIVE TO THE LOCALIZER, NOR WAS AN INQUIRY MADE AS TO THE PILOT'S INTENTIONS. IN ADDITION, THE VECTOR PROVIDED TO INTERCEPT THE LOCALIZER COURSE RESULTED IN AN INTERCEPT ANGLE OF 40 DEG; THE ATC HANDBOOK STIPULATES A MAXIMUM INTERCEPT ANGLE OF 30 DEG.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

THE PILOT'S FAILURE TO FOLLOW THE PUBLISHED MISSED APPROACH PROCEDURE, AND HIS FAILURE TO OBTAIN AND/OR MAINTAIN ADEQUATE ALTITUDE TO AVOID COLLISION WITH THE TERRAIN. FACTORS IN THE ACCIDENT WERE: THE PILOT'S LACK OF INSTRUMENT FLYING EXPERIENCE, AND THE CONTROLLER'S FAILURE TO FOLLOW STANDARD PROCEDURES AND TO PROVIDE MORE COMPLETE AND HELPFUL GUIDANCE TO THE INEXPERIENCED PILOT DURING THE APPROACH.

Full narrative available

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