Crow Wing County Regional Airport
Aircraft Accident/Incident Report

Brainerd, Minnesota 56401
Friday, June 17, 1994 10:55 CDT

NTSB Narrative Summary Released at Completion of Accident

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.

NTSB Probable Cause Narrative

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.

Event Information

Type of Event Accident
Event Date 6/17/1994
Event Day of the Week Friday
Time of Event 1055
Event Time Zone Central Daylight Time
Event City BRAINERD
Event State MINNESOTA
Event Country --
Zipcode of the event site 56401
Event Date Year 1994
Event Date Month 6
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude
Event Location Longitude
Event Location Airport CROW WING COUNTY REGIONAL
Event Location Nearest Airport ID BRD
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 3
Degrees magnetic from airport 114
Airport Elevation 1226
Weather Briefing Completeness Full
Investigator's weather source Weather Observation Facility
Time of the weather observation 1051 Central Daylight Time
Direction of event from weather observation facility (degrees) 294
Weather Observation Facility ID BRD
Elevation of weather observation facility 1226
Distance of event from weather observation facility (units?) 3
Time Zone of the weather observation CDT
Lighting Conditions Day
Lowest Ceiling Height 500
Lowest Non-Ceiling Height 500
Sky/Lowest/Cloud Conditions Partial Obscuration
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 3
Air Temperature at event time (in degrees celsius) 16
Dew Point at event time (in degress fahrenheit) 15
Wind Direction (degrees magnetic) 0
Variable Wind Indicator Variable
Wind Speed (knots) 0
Wind Velocity Indicator Calm
Wind Gust Indicator Not Gusting
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 30
Density Altitude (feet) --
Intensity of Precipitation Light
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal 3
Injury Total Minor --
Injury Total None --
Injury Total Serious 1
Injury Total All 4
Investigating Agency NTSB
NTSB Docket Number (internal use) 1175
NTSB Notification Source --
NTSB Notification Date Jun 17 1994 12:00AM
NTSB Notification Time 1400
Fiche Number and/or location -used to find docket information IMAGE
Date of most recent change to record Dec 6 2000 11:25AM
User who most recently changed record dbo
Basic weather conditions Instrument Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N1525G
NTSB Number BFO94FA103
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? --
Damage Destroyed
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name BEECH
Aircraft Model A-36
Aircraft Series Identifier A-36
Aircraft Serial Number E-2462
Certified Max Gross Weight 3650
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 6
Number of Engines 1
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection 100 Hour
Date of Last Inspection Jan 7 1994 12:00AM
Airframe hours since last inspection 110
Airframe Hours 1260
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name DUNCAN AVIATION INC. & T.HAYES
Aircraft Owner Street Address P.O. BOX 81887
Aircraft Owner City LINCOLN
Aircraft Owner State NE
Aircraft Owner Country
Aircraft Owner Zipcode 68501
Operator is an individual? --
Operator Name DUNCAN AVIATION INC. & T.HAYES
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address P.O. BOX 81887
Operator City LINCOLN
Operator State NE
Operator Country
Operator Zip code 68501
Operator Code
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation Unknown
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code LNK
Departure City LINCOLN
Departure State NE
Departure Country
Departure Time 900
Departure Time Zone CDT
Destination Same as Local Flt crash at destination city
Destination Airport Code
Destination City
Destination State
Destination Country
Specific Phase of Flight Approach
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 2 2001 10:34AM
User who most recently changed record dbo
Since inspection or accident --
Event Location Runway Number and Location 23
Runway Length 6500
Runway Width 150
Sight Seeing flight No
Air Medical Flight No
Medical Flight --