BEECH A36

Full Narrative

HISTORY OF FLIGHTOn May 01, 2023, about 1359 Pacific daylight time, a Beech A36 Bonanza, N2038Y, was substantially damaged when it was involved in an accident near Big Bear City, California. The pilot and two passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.
According to a witness, the purpose of the flight was to conduct an airplane pre-buy inspection for one of the passengers at Big Bear City Airport (L35), Big Bear City, California. The airplane departed French Valley Airport (F70), Murietta/Temecula, California, about 1122 and landed at Corona Municipal Airport (AJO), Corona, California, about 1136. The airplane departed AJO about 1332 with the intended destination of L35.
According to ADS-B data, during the transition from the airport traffic pattern’s base leg to final approach, the airplane overshot the landing runway centerline. While on short final, about 1359:35, the airplane’s groundspeed decreased to 66 knots. Video surveillance footage revealed that the airplane banked right, entered a rapid descent, and within a few seconds, the airplane recovered to a level attitude. However, about 1359:43, the airplane’s right wing dropped, a rapid right bank ensued, and the airplane descended rapidly and impacted terrain. PERSONNEL INFORMATIONAccording to the pilot’s most recent FAA medical certification, dated May 11, 2022, he self-reported that his civil flight experience included 2,000 total hours of flight experience and 50 hours within the 6 months before the exam. Only one pilot logbook was made available to investigators. A review of available logbook indicated that777.2 hours were forwarded from another source, and it is unknown what type of airplane was flown for those hours. The logbook showed the pilot completed a flight review on September 7, 2019. Although improperly annotated, most pilot logbook entries in the available logbook indicated that the primary aircraft flown by the pilot was the accident airplane. The pilot’s total flight experience as of November 1, 2020, was 983 hours.
An aircraft flight log was provided for the accident airplane, with the initial entry dated May 21, 2020, and the last entry dated November 1, 2020. The airplane’s flight log contained a total of seven entries. Two entries dated July 30, 2020, and September 1, 2020, were missing from the airplane’s flight log, but were annotated in the pilot’s logbook. Additionally, the airplane’s flight log indicated that, for a flight on October 23, 2020, the total flight time was 1 hour, but the pilot’s logbook indicated that the total flight time was 3 hours. AIRCRAFT INFORMATIONThe airplane’s flight log indicated that the airplane was purchased on January 1, 2020. According to the provided engine, airframe, and propeller maintenance records, the last annual inspection was completed April 2, 2021. The engine logbook indicated that upon completion of the last annual inspection, the tachometer time was 3,666.2 hours, and the time since overhaul was 1,754.62 hours. The airframe logbook indicated that the airframe total time was 3,666.62 hours. The propeller logbook indicated that the time since overhaul was 656.62 hours, and the logbook tachometer time was consistent with the engine and airframe total hours. METEOROLOGICAL INFORMATIONA search of the FAA contracted Automated Flight Service Station provider, Leidos Flight Service, records indicated that there was no contact from the pilot for any weather briefing information on the day of the accident. A separate search of ForeFlight weather products indicated that the pilot did not have an account, and no weather briefings or flight plans were filed for N2038Y on the day of the accident. It is unknown what weather information, if any, the pilot checked or received before or during the accident flight.
The closest weather reporting facility to the accident site is located at L35, about 0.5 miles west of the accident site. The airport is located east of Big Bear Lake and surrounded by mountainous terrain on all quadrants. Sugarloaf Mountain is located 5 miles south of the accident site at 9,952 ft. The airport had an AWOS, which was not augmented by any human observers and transmitted locally on 135.925 Megahertz (MHz) and broadcast observations to users every 20 minutes. Surrounding the time of the accident the following conditions were reported:
At 1355, wind was 11 kts from 240° gusting to 18 kts, visibility 10 statute miles or more, sky clear below 12,000 ft agl, temperature 13° C, dew point temperature -13° C, and altimeter 29.84 inches of mercury (inHg).
At 1415, wind was 6 kts from 220° gusting to 19 kts, visibility 10 statute miles or more, sky clear below 12,000 ft agl, temperature 13° C, dew point temperature -11° C, and altimeter 29.84 inHg.
While the wind generally prevailed from the southwest during the observations, there were numerous variations of up to 60° in wind direction reported during the period.
Multiple pilot reports (PIREPs) were issued before the accident, which reported on the atmospheric conditions that were generally south of the accident site. At 1450 a PIREP from a pilot of a B-737 departing Palm Springs International Airport (PSP) Palm Springs, California, reported the wind from 310° at 27 knots gusting to 36 knots, with a loss of 25 knots of airspeed on departure. There was also a single report of moderate turbulence from a Cirrus SR22 at 12,000 ft about 20 miles to the southwest of the accident site.
The NWS issued an urgent weather advisory about 1300. The urgent advisory identified that the accident site area was expected to encounter wind from the southwest at 25 to 35 mph with gusts to 60 mph. Additionally, the NWS issued a G-AIRMET valid for occasional moderate turbulence below 16,000 ft over the accident site, and advisories for mountain obscuration and strong surface winds immediately bordering the accident site.
The National Oceanic Atmospheric Administration (NOAA’s) HRRR sounding thermodynamic and wind profiles indicated mountain wave development over the area. NOAA’s Geostationary Operational Environmental Satellites (GOES) imagery indicated localized mountain wave activity with potential updrafts and downdrafts in the vicinity of the accident site at the time of the accident.
The FAA published Advisory Circular (AC) 00-57 “Hazardous Mountain Winds and Their Visual Indicators” to assist pilots in diagnosing the potential for severe wind events in the vicinity of mountainous areas. Vertical propagating mountain waves and trapped lee waves were confirmed in the area during the time of the accident. The AC stated that the consequences for a pilot flying through propagating mountain waves include airspeed and altitude deviations and the possible sudden onset of severe or extreme turbulence. Often accompanying these high-altitude effects is the occurrence of very strong surface winds in the form of downslope winds that create a low-level hazard to all aircraft. Further, these extreme low-level winds often terminate abruptly in a hydraulic jump located some distance away from the mountain’s lee slope.
The University Corporation for Atmospheric Research WRF Model produced over the region between 1300 through 1500 also depicted conditions favorable for mountain wave activity and a potential hydraulic jump. The “jump” is noted in the horizontal and vertical velocity wind fields and in the streamline analysis as a convergence zone with vortices. The jump region was identified moving across the accident site area about 1300, with strong upward vertical motion of 200-800 fpm followed by downdrafts. AIRPORT INFORMATIONThe airplane’s flight log indicated that the airplane was purchased on January 1, 2020. According to the provided engine, airframe, and propeller maintenance records, the last annual inspection was completed April 2, 2021. The engine logbook indicated that upon completion of the last annual inspection, the tachometer time was 3,666.2 hours, and the time since overhaul was 1,754.62 hours. The airframe logbook indicated that the airframe total time was 3,666.62 hours. The propeller logbook indicated that the time since overhaul was 656.62 hours, and the logbook tachometer time was consistent with the engine and airframe total hours. WRECKAGE AND IMPACT INFORMATIONThe airplane impacted the ground in a nose-down, right bank on a heading of 310° magnetic. The right wing struck the ground, forming the initial point of impact, as confirmed by ground scars that contained fragments of the green position light lens. The right wing created a ground scar about 45 ft long, and a subsequent ground scar was created by the nose of the airplane. The ground scars revealed a pivot point from the nose of the aircraft, followed by a cartwheel motion over to the left wing before the airplane came to rest in a near upright position. Both wings sustained impact damage from the outboard wing section and were fracture-separated near the aileron bellcranks. The right aileron separated from the outboard wing section. The left aileron remained attached to the left outboard wing. The left-wing fuel tank was breached, but the right-wing fuel tank was not breached and contained about 25 gallons of fuel. The engine was partially separated from the fuselage, and the propeller was separated from the engine at the crankshaft.
The left flap was observed in the fully extended position. The right flap was observed in the retracted position; however, further investigation revealed that the flap actuator was in the fully extended position, and damage was observed to the flap at the actuator attachment point. The left main and nose landing gear were observed extended, and the right main gear collapsed. The control rod for the right main gear was observed with impact damage near the central actuator bellcrank. The actuator was observed in the gear extended position. The landing gear switch in the cockpit was also observed in the gear extended position.
The empennage remained attached to the aft fuselage, and minimal damage was sustained to the right side horizontal stabilator, elevator, and trim tab. The left side horizontal stabilator, elevator, and trim tab sustained impact damage, which created an upward bow from the top of each surface that emanated from the outboard section to the fuselage. The aft left fuselage sustained impact damage identified with concave signatures consistent with the horizontal stabilator and elevator impacting the ground. The vertical stabilizer sustained impact damage near its fuselage mating surface and the rudder attachment points. The rudder revealed crushing signatures emanating from the top aft section, which bent the airfoil to the right, as indicated by the concave signatures at the top and midspan vertical stabilizer attachment points when viewed from the right side.
During the occupant rescue and recovery efforts, first responders separated the overhead cabin from the forward fuselage at the windshield area and it was peeled back over the aft fuselage. Both forward seats were observed removed from the aircraft.
Postaccident examination of the airframe and engine revealed no preimpact failures or anomalies that would have precluded normal flight operations. MEDICAL AND PATHOLOGICAL INFORMATIONThe San Bernardino County Coroner conducted an autopsy of the pilot’s remains. The autopsy indicated that the cause of death was multiple blunt force injuries, and the manner of death was accident.
Toxicology testing performed by the FAA Forensic Sciences Laboratory found no drugs of abuse. USEFUL OR EFFECTIVE INVESTIGATION TECHNIQUESNTSB Research and Engineering staff reviewed the airplane’s performance using the available ADS-B data and the environmental conditions over the accident site that existed during the time of the accident. The review used wind conditions at 7,500 ft msl and indicated that the wind was from the southwest at 210° and a wind speed of 17 knots. The study revealed that on the base leg of the airport traffic pattern, the airplane was on a northerly heading, and the airplane’s groundspeed was 111 kts, with an airspeed of 85 kts. The pilot initiated a left turn from base to final (see figure 1) at an airspeed of 89 kts and overshot the runway centerline about 1359:10. The airplane continued the final leg of the approach, and about 1359:35, the airplane’s airspeed decreased to 65 kts. The performance data indicated that the stall break occurred on short final at 1359:43.
A 17-knot tailwind combined with the high airport elevation produced a groundspeed much greater than the airspeed (see figure 2). The airspeed and groundspeed come together at 1359:15 (see figure 2), when the airplane turns onto final. The performance review noted that the high groundspeed provided insight as to why the flight overshot the extended runway centerline. The ADS-B data indicated that the pilot attempted to align the airplane with the runway by making a 20° left turn while on final. However, that’s also when the airplane appeared to have stalled.

Figure 1: ADS-B Overlay Close to Airport

Figure 2: ADS-B Altitude, Rate of Climb, Ground Speed, and Estimated Airspeed

Figure 3: Estimated Pitch, Bank, and Heading Angles