Event CEN22FA023

Factual narrative

HISTORY OF FLIGHTOn October 31, 2021, about 1334 mountain daylight time (all times MDT), a Beech P35 Bonanza airplane, N8625M, was substantially damaged when it was involved in an accident near Harrison, Nebraska. The pilot, passenger, and a dog were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal cross-country flight. The airplane departed Marion Municipal Airport (MNN), Marion, Ohio, about 0600 for the first leg of the flight and was destined for Marshalltown Municipal Airport, (MIW), Marshalltown, Iowa, which was about 454 nautical miles (nm) away. The pilot had filed an IFR flight plan for the first leg and was in contact with ATC. The airplane landed at MIW about 0930 and the pilot added 49.5 gallons of aviation gasoline. There was no flight plan filed for the second leg from MIW to Converse County Airport (DGW), Douglas, Wyoming, which was about 555 nm from MIW. Recorded ATC communications revealed that the controllers experienced difficulty communicating with the pilot en route. At 1011, a few minutes after he departed from MIW, the pilot called ATC at 4,500 ft msl and requested VFR flight following and then reported that the frequency was breaking up. At 1015, the pilot checked in with another controller and reported to the controller that he was VFR at 4,500 ft msl. At 1143, the controller changed the pilot to a different frequency, but the pilot did not respond. At 1144, the controller broadcasted for the pilot, but there was no response. The controller then coordinated with an adjacent ATC sector for a communication relay through another airplane. At 1148, the accident pilot reported on the controller’s frequency, then the controller advised that radar contact was lost. In the next 10 minutes, the controller requested that the pilot recycle the transponder and advised that the airplane was still not visible on radar. Finally, at 1205, the controller terminated VFR flight following. Automatic dependent surveillance-broadcast (ADS-B) data revealed that the airplane departed MIW at 1004 with an en route cruise altitude between 4,400 ft and 5,300 ft msl and about 140 kts groundspeed. There were several areas along the route of flight that were not recorded by any radar or ADS-B sources. A witness reported that while flying his airplane about 15 miles south of Valentine, Nebraska, about 1215 to 1230, he observed a white V-tail Bonanza with red stripes. (Note: This area was along the accident airplane’s estimated route of flight.) The airplane was headed west toward the weather and passed above him about 5,000 ft msl. He was aware of two active airman’s meteorological information (AIRMETs) advisories for icing conditions to the west and southwest of his location, and he tried to radio the accident pilot to warn him of the icing conditions, but he did not receive a response. At 6,500 ft msl, the outside air temperature was 28° F where he had previously encountered trace to light icing before he had descended to 4,500 ft msl where the temperature was 38° F. At 13:33.18, ADS-B data showed the accident airplane at 5,275 ft msl and descending toward rising terrain. From 13:33.30 to 13:33.37 the airplane was about the same altitude as the terrain, as seen in Figure 1, and then began a climb to 5,500 ft msl (320 ft agl), about 125 kts groundspeed. The final data point was recorded at 13:33.52 at 5,400 ft msl (250 ft agl) and 150 kts groundspeed. Figure 1. End of accident flight path and accident site, Google Earth view. The flight track descends toward rising terrain, which increases in elevation by 800 to 1,000 ft. PERSONNEL INFORMATIONThe pilot’s logbook showed that the pilot had accumulated 1,269.6 total hours, and that he just recently started flying again in April 2021. Before that he had not flown since 1978. As of September 10, 1978, he had accumulated 1,215.3 total hours. As of April 23, 2021, when the pilot started flying again, he had accumulated 54.3 total hours, all of which were in the accident airplane. From September 9 to 11, 2021, he completed 3 IFR training flights for a total of 4.9 hours, 3.4 of which were simulated instrument instruction. During those simulated instrument flights he completed holding procedures, several instrument approaches, and other IFR-related procedures. AIRCRAFT INFORMATIONThe airplane featured two 40-gallon wing fuel tanks with 74 gallons of usable fuel. At 65% of maximum continuous power, the airplane’s range would have been up to about 800 nautical miles and the endurance about 5.5 hours of flight time. The airplane was not equipped with any anti-icing or de-icing equipment, which would have been required for flight into known icing conditions, in accordance with 14 CFR 91.527, Operating in icing conditions. The day of the accident was the last day before an annual inspection was required to be completed. According to the airplane mechanic, the airplane was scheduled to undergo an annual inspection on November 1, 2021, the day after the accident. METEOROLOGICAL INFORMATIONThe night before the accident, the pilot obtained a ForeFlight weather briefing and filed an IFR flight plan for the first leg of the flight but did not file a flight plan for the second leg. The pilot reviewed several ForeFlight weather products at that time and a general route briefing was generated. The pilot also entered several route strings from MIW to DGW from 2,500 ft msl through 6,000 ft msl but did not generate a weather briefing for the accident route. There were no records that indicated the pilot received any other updates from ForeFlight on October 31, 2021. There was no record of any updates from the contract Flight Service Station provider, Leidos, or any other third-party vendors for any weather briefings, inflight contacts, or flight plans. The National Weather Service (NWS) Weather Prediction Center (WPC) 12-hour Surface Forecast chart depicted a high-pressure system over Nebraska with the stationary front to the southwest over Colorado with little change in position. A mixed band of freezing precipitation and snow was depicted over western Nebraska, northern Colorado, and Wyoming, and extended over the accident site. The NWS Aviation Weather Center (AWC) issued inflight weather advisories in the form of AIRMETs for IFR conditions over the accident site and for moderate icing conditions from the freezing level to 21,000 ft. The NWS graphical forecasts for aviation and inflight weather advisories included warnings of IFR conditions and icing conditions applicable to the accident site at the time of the accident. A witness, who was located southeast of Crawford, Nebraska, and about 10 miles south of the accident airplane’s flight path, stated that he heard a low flying airplane between 1330 and 1400. The weather conditions included an overcast cloud layer about 200 ft agl, one mile of visibility, and “heavy freezing drizzle with ice particles.” Weather data indicated low ceilings with light freezing rain over the accident site, which was confirmed by two weather reporting sites in Harrison, Nebraska, and two witnesses. The data depicted light-to-moderate clear icing below 5,500 ft with rime icing conditions above through 11,000 ft, which was the estimated top of the nimbostratus type clouds. The pilot reports over the region confirmed light-to-moderate rime and mixed icing reported about the time the accident flight was in the area. The closest recorded weather station was Chadron Municipal Airport (CDR), Chadron, Nebraska, located about 40 miles east of the accident site and along the route of flight at an elevation of 3,298 ft msl. The airport’s automated surface observation system was not augmented by any human observers. At the time the airplane passed about 4 miles south of CDR, the following conditions were reported: Weather observation for CDR at 1253 MDT, automated, wind from 100° at 4 kts, visibility 10 miles or more, ceiling overcast at 4,500 ft agl, temperature 2° Celsius (C), dew point temperature -4° C, altimeter setting 30.35 inches of mercury (inHg). Remarks: automated station with a precipitation discriminator, sea-level pressure 1030.7-hPa, temperature 1.7° C, dew point -4.4° C. AIRPORT INFORMATIONThe airplane featured two 40-gallon wing fuel tanks with 74 gallons of usable fuel. At 65% of maximum continuous power, the airplane’s range would have been up to about 800 nautical miles and the endurance about 5.5 hours of flight time. The airplane was not equipped with any anti-icing or de-icing equipment, which would have been required for flight into known icing conditions, in accordance with 14 CFR 91.527, Operating in icing conditions. The day of the accident was the last day before an annual inspection was required to be completed. According to the airplane mechanic, the airplane was scheduled to undergo an annual inspection on November 1, 2021, the day after the accident. WRECKAGE AND IMPACT INFORMATIONThe remote accident area consisted of small rolling hills at an elevation of 5,140 ft msl. The accident site was defined by an initial impact crater and a debris field about 700 ft long at 5,160 ft msl elevation. There was airplane debris scattered from the initial impact point to the main wreckage. The engine and propeller and a few pieces of debris were found southwest of the main wreckage. The airplane impacted the ground with the wings relatively level and at a shallow descent angle. Figure 2 shows the final locations of the airplane, engine, and propeller within the debris field. Figure 2. Aerial image of the accident site (Source: Sioux County Sheriff’s Office). The rudder and elevator control cables were continuous from the cockpit controls to the respective flight control surfaces with no separations or anomalies. The rudder interconnect torque tube between the left and right pedals was broken on both sides and impact damaged. The aileron control cables had been cut at the wing roots during the wreckage recovery process. One arm of the left aileron bellcrank was separated due to impact forces. Otherwise, the aileron controls were continuous with no anomalies. The elevator trim actuator was found near neutral. Both flap actuators were in a retracted position. The pitot heat switch was found OFF, the defrost switch was OFF, and the cabin heat knob was pulled out slightly. The vertical speed indicator needle was seized and was positioned to -5,500 fpm descent. The airspeed indicator was indicating about 200 kts. The engine had separated from the firewall and came to rest southwest of the main wreckage. The bottom of the engine sustained significant impact damage and most of the oil sump was impact separated. The propeller had separated from the crankshaft flange and the bolts were all sheared. The blades were both bent aft about midspan. One blade exhibited significant leading edge impact gouges and scoring. The engine’s crankshaft was unable to rotate due to impact damage. The crankshaft was visible from the bottom of the case with the oil sump removed. The inside of the case, crankshaft, and camshaft appeared intact with no anomalies noted. There were no preimpact mechanical malfunctions or failures with the airplane or engine that would have precluded normal operation. MEDICAL AND PATHOLOGICAL INFORMATIONAn autopsy of the pilot was performed by the Western Pathology Consultants, Regional West Medical Center, Scottsbluff, Nebraska. The autopsy report was reviewed by the National Transportation Safety Board Investigator-In-Charge. According to the autopsy report, the cause of death was multiple blunt force injuries, and the manner of death was accident. The laceration the right hand was consistent with a [flight] control injury. Toxicology testing performed by the Federal Aviation Administration’s (FAA) Forensic Sciences Laboratory on the pilot’s blood and urine detected quinine, which is not generally considered impairing. The night before the accident, the instrument-rated pilot received a weather briefing for the first leg of a multi-leg cross country flight and filed an instrument flight rules (IFR) flight plan. The next morning, the pilot and passenger completed the first leg and serviced the airplane with 49.5 gallons of aviation gasoline. The pilot had not received a weather briefing or filed a flight plan for the second leg of the flight but was in contact with air traffic control (ATC) and received visual flight rules (VFR) flight following for the first portion of the flight. The controllers experienced difficulty communicating with the pilot and the radar coverage was intermittent. About 2 hours into the flight, the controller advised that the airplane was still not visible on radar and terminated VFR flight following. Recorded flight track information revealed that the airplane continued west toward the destination airport. About 15 to 30 minutes later, the pilot of another airplane observed the accident airplane headed west. Since he knew there were icing conditions and bad weather ahead, he attempted to radio the pilot but did not receive a response. About an hour later, the airplane’s flight track descended toward rising terrain, where it was briefly at the same elevation as the terrain, then climbed to about 320 ft above ground level (agl). The final flight track point showed the airplane at 250 ft agl and 150 kts groundspeed. The airplane impacted open terrain with a shallow descent angle and the wings relatively level, then came to rest upright about 700 ft later. The end of the debris field was defined by the engine and propeller, which had separated from the airplane during the accident sequence. General fragmentation and the length of the wreckage debris field were indicative of a high-speed impact. Postaccident examination of the airplane did not reveal any preimpact mechanical malfunctions or failures that would have precluded normal operation. The airplane was likely operating in instrument meteorological conditions and in mixed freezing precipitation and snow at the time of the accident. If the pilot had obtained an adequate weather briefing, he likely would have been made aware of the adverse conditions and could have been able to alter his course to avoid the conditions. The conditions at the airport with the closest recorded weather station, directly along his route of flight, could have been a safe alternate airport. Based on the flight track and weather conditions at the time of the accident, it is likely that the pilot was attempting to avoid instrument and icing conditions; he unknowingly descended toward rising terrain, then rapidly climbed to avoid the terrain, which resulted in a loss of control. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12

NTSB Findings

Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).

• — Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Low visibility-Contributed to outcome
• — Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Freezing rain/sleet-Contributed to outcome
• — Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Pilot
• — Personnel issues-Task performance-Planning/preparation-Weather planning-Pilot