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ASN Wikibase Occurrence # 220647
Last updated: 25 September 2021
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Date:07-JAN-2019
Time:11:50 LT
Type:Silhouette image of generic B36T model; specific model in this crash may look slightly different
Beechcraft A36TP Bonanza (Soloy turbine conv.)
Owner/operator:Chalk Hills Consulting Group LLC
Registration: N100JB
MSN: E-2203
Fatalities:Fatalities: 2 / Occupants: 2
Aircraft damage: Written off (damaged beyond repair)
Category:Accident
Location:Colusa County retention pond, Colusa, CA -   United States of America
Phase: En route
Nature:Private
Departure airport:Colusa, CA (O08)
Destination airport:Palo Alto, CA
Investigating agency: NTSB
Narrative:
The pilot, who did not possess a current medical certificate, departed in instrument meteorological conditions on a cross-country flight with a passenger onboard. A witness at the departure airport reported that at the time of takeoff, the cloud ceiling was about 500 ft above ground level with visibility of about 1 mile. Radar information revealed that the airplane turned to a southwesterly heading after departure, consistent with a heading toward their intended destination. The data showed that about 10 seconds after takeoff, as the airplane ascended through about 725 ft mean sea level (msl), a right turn was initiated. During the initial portion of the turn, the airplane continued to ascend to about 825 ft msl, where it remained for about 7 seconds. The airplane then began a descent while remaining in the right turn until impact.
Maneuvering the airplane in restricted visibility placed the pilot in conditions conducive to the development of spatial disorientation. The accident circumstances, including the tightening descending turn, and the subsequent high-energy impact, are consistent with the known effects of spatial disorientation. Additionally, examination of the engine revealed no evidence of any preexisting anomalies that would have precluded normal operation. Part of the flight control system was highly fragmented and could not be examined; however, the portions that remained intact did not exhibit any preexisting anomalies. Therefore, it is likely that the pilot was experiencing the effects of spatial disorientation when the accident occurred.
The pilot's autopsy revealed severe cardiac disease, and although incapacitation as a result of this was possible, the pilot's loss of control suggests spatial disorientation was a more likely initiating event. Thus, it is unlikely that any symptoms from the pilot's severe cardiac disease contributed to this accident. The pilot also had bipolar disorder, but the extent of symptoms and whether they contributed to the accident could not be determined from the available information. However, the pilot had an established history of using medications to control the disease; therefore, some of the negative effects may have likely improved.

Probable Cause: The pilot's loss of airplane control due to spatial disorientation shortly after takeoff in instrument meteorological conditions.

Sources:


https://flightaware.com/live/flight/N100JB

FAA register: https://registry.faa.gov/aircraftinquiry/NNum_Results.aspx?NNumbertxt=100JB

NTSB WPR19LA058

Accident investigation:
cover
  
Investigating agency: NTSB
Status: Investigation completed
Duration:
Download report: Final report
Location

Media:


Revision history:

Date/timeContributorUpdates
08-Jan-2019 20:45 Captain Adam Added
08-Jan-2019 22:46 Geno Updated [Location]
08-Jan-2019 23:51 Iceman 29 Updated [Embed code, Damage, Narrative]
10-Jan-2019 13:25 RobertMB Updated [Time, Source, Embed code]
15-Jan-2019 03:06 RobertMB Updated [Aircraft type, Registration, Cn, Source]
15-Jan-2019 14:50 Geno Updated [Operator, Departure airport, Destination airport, Source]
31-Mar-2021 13:56 ASN Update Bot Updated [Time, Other fatalities, Departure airport, Destination airport, Source, Narrative, Category, Accident report]
31-Mar-2021 14:05 harro Updated [Aircraft type, Phase, Source, Narrative]

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