LAX94LA045
LAX94LA045

HISTORY OF FLIGHT

On November 14, 1993, at 1950 hours mountain standard time, a Beech A-36, N9MP, collided with desert terrain near Florence, Arizona, after a reported loss of power. The pilot was conducting an instrument flight rules (IFR) personal flight to Tucson, Arizona. The airplane, operated by Wasatch New Horizons, Inc., Heber City, Utah, sustained substantial damage. The certificated private pilot and the right front seat passenger received serious injuries; one passenger sustained minor injuries, and six passengers were not injured. The flight originated at Heber City, Utah, at an undetermined time. Night instrument meteorological conditions prevailed at the time.

There was no record that the pilot received an aviation briefing from the Cedar City Flight Service Station, Cedar City, Utah, prior to departure. An airman's meteorological information advisory (AIRMET) was issued for the pilot's route of flight. The AIRMET forecasted occasional moderate mixed icing during the flight between 6,000 feet mean sea level (msl) and 18,000 feet msl.

At 1956 hours, the pilot contacted Prescott Automated Flight Service Station (hereby referred to as AFSS), and requested the current Phoenix and Tucson weather. The briefer at the flight service station asked the pilot if he "had the flight precautions going that way." The pilot replied, "negative."

Prescott AFSS reported the following in part, "low ceilings and visibilities are predicted from ah Prescott to just north of Phoenix all the way to Tucson...icing is forecast moderate mixed icing from seven thousand up to flight level one eight zero and turbulence is possible at any altitude below sh moderate turbulence below any altitude at thirty eight thousand feet and the mountains are forecast to be locally obscured over most of the state of Arizona..."

At 1857 hours, the pilot told Prescott AFSS that, "I'd like to ah pick up an IFR (instrument flight rules) flight plan ah, into ah, probably Phoenix ah, I just got up into the clouds about ten and I'm picking up a little bit of ice."

During the next minute, there were several attempts by the pilot to contact Prescott AFSS to file an IFR flight plan. The pilot made several inquiries to Prescott AFSS about conditions in various locations throughout the state of Arizona. At 1859 hours, the pilot told Prescott AFSS, "Ok, ah nine mike papa ah, ah, Tucson doesn't look very good."

Prescott AFSS told the pilot, "November niner mike papa, VFR (visual flight rules) is not recommended ah across this state at all because of a flight precaution for low for solid overcast ceilings and mountain obscuration..."

During the next three minutes, Prescott AFSS made several attempts to contact the pilot of the accident airplane to gather the information necessary to file the IFR flight plan. According to the transcript of the conversation between the pilot and Prescott AFSS, there were several broken up transmissions and squeals on the radio which rendered communication difficult. At 1906 hours, Prescott AFSS told the pilot to "contact Albuquerque Center on frequency 135.72."

At 1933 hours, the pilot contacted Albuquerque Air Route Traffic Control Center (ARTCC), about 67 miles northwest of Tucson, Arizona, and stated, "a yes I'd like to pick up an IFR clearance into Tucson...I'm about ah I show sixty seven ah DME (distance measuring equipment) out of Tucson."

The sector controller issued the pilot an IFR clearance and instructed the pilot "squawk two six one four." At 1935 hours, the sector controller said, "Bonanza niner mike papa radar contact six four miles north of Tucson VORTAC cleared to Tucson via direct climb and maintain one two thousand, Tucson altimeter two niner eight four." The pilot repeated the clearance he was given.

At 1940 hours, while climbing, the pilot reported to ARTCC that the airplane was "picking up a little uh ice uh, and requested to stay at eleven thousand (feet mean sea level)." The sector controller cleared the pilot to 11,000 feet msl.

At 1942 hours, the pilot requested, "is there any way you can give me any lower, I'm pickin up quite a bit of ice..." The sector controller cleared the pilot to maintain block seven thousand through one one thousand.

At 1945 hours, the pilot then reported he was "having engine trouble...I'm freezing up." At 1947 hours, the sector controller asked the pilot if he was able to "maintain altitude now." The pilot of the accident airplane responded "nine pike papa uh negative." The sector controller informed the pilot of the location of the Coolidge Municipal Airport and asked the pilot to let him know if he needed to divert.

At 1947 hours, the pilot informed the controller that "uh nine mike papa ...uh I just lost everything uh all my controls uh I'm I'm in trouble here." The controller gave the pilot radar vectors to the Coolidge Municipal Airport. The pilot responded at 1948 hours, "ok nine mike papa two seven zero, uh uh I I've really lost her here though." The last communication that the sector controller received from the pilot was that "I've lost all rudder control...the engine is not operating," which was transmitted at 1949 hours.

The sector controller received a transmission from Southwest Airlines Flight 1595, "yes sir, we were monitoring that uh with that bonanza and uh we're now picking up an ELT on uh twenty one five."

A crew from the Arizona Department of Public Safety (DPS), Southern Air Rescue, Tucson, Arizona, was notified at 2015 hours by their DPS dispatch of "an aircraft going down." The pilot of the mission reported that he checked weather in the area prior to departing on the rescue mission. He reported that the "weather in Tucson and Arizona had been worsening all day." He reported that the Tucson Flight Service Station told him in part, "moderate icing above 6,000 feet mean sea level, moderate turbulence, mountain obscuration in clouds and fog."

The DPS rescue unit departed Tucson at 2035 hours, and attempted to reach the accident site. They were forced to abort their mission three times due to "limited visibility and heavy rain." The DPS rescue unit flew to the Florence,Arizona, hospital to wait for better weather. Meanwhile, they directed ground crews to the location of the crash site.

CREW INFORMATION

The pilot's logbook detailing his aeronautical experience was recovered from the pilot's wife. The last entry made in the logbook was on November 2, 1993. As of that date, the pilot had logged a total of 3,032 flight hours. Logbook entries made by the pilot showed a total of 65.3 hours of simulated instrument experience and 8.0 hours of actual instrument experience.

According to the Federal Aviation Administration (FAA) inspector who reviewed the logbooks, the pilot was not instrument current in accordance with current Federal Aviation Regulation 61.57(e). According to the FAA Airman Certification Branch, the pilot was issued his instrument rating on April 23, 1992.

AIRCRAFT INFORMATION

The airplane's airframe and engine logbooks were recovered from the pilot's wife. An examination of the logbooks did not reveal any unresolved discrepancies prior to departure the day of the accident. According to the airplane manufacturer, under the "Limitations" section of the Beechcraft Bonanza A36TC Pilot Operating Manual, "flight in icing conditions prohibited." (See section 8.5 for additional information.)

METEOROLOGICAL INFORMATION

The nearest weather reporting station to the accident site is located at Phoenix Sky Harbor International Airport about 48 nautical miles northwest of the accident site. The observation taken at 1950 hours local, the evening of the accident, was in part: "3,500 broken, 8,500 overcast, visibility eight in light rain, temperature 49 degrees Fahrenheit, dew point 46 degrees Fahrenheit, wind 060 degrees at 11 knots, altimeter 29.80 inHg." Three hours earlier, at 1657 hours local, the freezing level was measured at 5,900 feet msl.

WRECKAGE AND IMPACT INFORMATION

According to the written report received from the parties to the investigation, the aircraft made initial contact with the top of a 20-foot Saguaro cactus, cutting off the top foot of the cactus. The aircraft then struck the ground on up-sloping terrain leaving two ground scars on a heading of 340 degrees. An antenna was found in the first ground scar, and the broken tip of a prop blade was found near the second scar. The aircraft came to rest 258 feet from the initial point of contact. The fuselage was resting on a heading of 058 degrees with part of the horizontal stabilizer embedded in another Saguaro cactus.

The nose of the aircraft was crushed upward, and the engine had separated from its mounts. There was scraping on the underside of the fuselage parallel to the longitudinal axis. Both wings and the empennage remained attached and were not extensively damaged. The flaps and landing gear were found in the retracted position.

Engine controls in the cockpit were damaged, and their position could not be determined. The throttle lever on the carburetor was closed, and the propeller lever at the propeller governor was at a low RPM setting. The manufacturer representative reported that the engine control cables all appeared to have been pulled during the impact sequence.

Flight control cable continuity was established from the rudder to the rudder pedals, from the elevators to the control column, and from the right to left aileron.

The fuel selector was found in the right main position. Two quarts of fuel was drained from the right fuel cell. Nine gallons of fuel was drained from the left fuel cell. Fuel was seen dripping from the left tank drain when the aircraft was lifted.

At least 36 hours after the accident, when the airplane was lifted during the recovery process, a patch of ice about four inches in diameter was found under the left wing in the area near the left main fuel drain. (For additional information, see attached photos.)

A weight and balance was computed by the airplane manufacturer using delivery document weight and balance information, a statement provided by the pilot's wife, and the aircraft recovery individual for the occupant and baggage weights. The calculations determined that the airplane was about 500 pounds over the takeoff maximum gross weight limit and its center of gravity exceeded the aft limit by 2.0 inches. With zero fuel, the airplane was still 50 pounds over the gross limit and the center of gravity exceeded the aft limit by 4.7 inches.

TESTS AND RESEARCH

The engine, a Continental TSIO-520-UB, was sent to the Continental factory for additional tests. The engine was installed in Teledyne Continental Motors Production Test cell number 41 on December 23, 1993. According to the report received from the Federal Aviation Administration representative who witnessed the engine runup, engine startup was "immediate." He said the engine was run at maximum obtainable power for ten minutes, after the engine was warmed up.

According to the enclosed memorandum, the turbocharger assembly had been torn off its mount and was returned loose in the shipping crate. The compressor/turbine could not be rotated. Under the guidance of the National Transportation Safety Board, the engine was prepared to run as a normally aspirated engine. The FAA report stated in part, that "the turbocharger intake housing was removed and the compressor/turbine rotated freely. There were some slight rub marks on the compressor housing from impact."

ADDITIONAL INFORMATION

The aircraft wreckage was released to Mr. Rex Thompson, Claimtex Insurance Company, representing the owner on January 5, 1993.

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