FLIGHT FINDINGSAVIATION OCCURRENCE MAP
Back to map

WPR16LA028 · Beech A36 UNDESIGNAT

12 Nov 2015 · Lancaster, CA, United States

Beech A36 UNDESIGNAT · Accident: controlled flight into terrain/object (CFIT) on approach

From Meadows Field (KBFL) to General William J Fox Airfield (KWJF)

Report a problem

Event

NTSB case
WPR16LA028
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Accident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
0 · all aircraft and ground
Ground fatalities
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
General aviation
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Visual Meteorological Cond

Beech A36 UNDESIGNAT

Aircraft type
Beechcraft 36
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N78CR
Operator
Unknown
Onboard fatalities
Unknown
Route
From Meadows Field (KBFL), Bakersfield, CATo General William J Fox Airfield (KWJF), Lancaster, CA
Aircraft age
About 40 years (built 1975)
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 91: General Aviation
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Approach · IFR initial approach
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Controlled flight into terrain/object (CFIT)
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Substantial

Cause areas

  • Aircraft › Aircraft oper/perf/capability
  • Personnel issues › Action/decision

Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.

NTSB narrative

The private pilot and flight instructor were conducting a three-leg cross-country flight in dark night, visual meteorological conditions on an instrument flight rules flight plan to an airport located in the vicinity of mountainous terrain. The pilot requested the RNAV approach, and the controller cleared the pilot direct to an intermediate fix for the approach. Three minutes later, the controller instructed the pilot to descend and maintain 7,000 ft. The airplane continued on its original heading for several minutes before turning toward the intermediate fix; the controller subsequently issued a 15o right turn to intercept the final approach course; however, the airplane turned left about 10o. The airplane continued on this heading for about 3.5 miles, when the controller cleared the airplane direct to the next fix along the approach (which should have resulted in the airplane turning left), with an altitude restriction at or above 7,000 ft until reaching the fix. The pilot incorrectly read back the fix, and the airplane turned right, likely toward the intermediate fix to which he had been previously cleared. The controller did not correct the pilot's readback of this clearance.

Several minutes later, at 7,250 ft, the pilot reported the intermediate fix inbound. The controller did not hear this transmission because he was on a landline with the tower controller at the time. Rather than turning onto the approach course, the airplane continued a southerly heading through the fix and the final approach course, and several minutes later, the pilot again asked the controller for an approach clearance. The controller cleared the airplane for the approach with no additional information. The airplane was not established on the published approach at that time, and as the airplane turned north/northwest to intercept the final approach course, it was well below the published minimum altitude for that segment of the approach. The controller subsequently asked the pilot if he had the terrain in sight, and the pilot first responded that he had the airport in sight. When asked again if he had the terrain in sight, the pilot responded that he did. The controller then instructed the pilot to contact the airport tower controller. At that time the airplane was at an altitude of 5,325 ft; the minimum altitude for that segment of the approach was 6,400 ft.

The airplane continued to descend along the final approach course; the last recorded radar position of the airplane was at an altitude of 4,150 ft and nearly coincident with the accident site. Both pilots reported to first responders that they thought they were flying too high, but instead they were too low, and that they flew into terrain. Both pilots also reported that there were no mechanical malfunctions of the airplane.

The circumstances of the accident are consistent with the flight instructor's failure to comply with the minimum published altitudes for the approach, which would have ensured terrain clearance. Although the controller likely recognized the airplane's low altitude, and as a result asked if they had the terrain in sight, it is likely that, had he issued a safety alert and instructed the pilots to climb, the collision with terrain may have been averted.

Probable cause

The flight instructor's failure to comply with published instrument approach procedures during an instrument approach in dark night, visual meteorological conditions, which resulted in impact with terrain. Contributing to the accident was the controller's failure to issue a safety alert upon noting the airplane's low altitude.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record WPR16LA028
Event ID
20151113X82718
Case number
WPR16LA028
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: local date, investigation status. Values present in the bulk record are kept.
  • The date is the local date; the NTSB stores the UTC date 2015-11-13.
  • API snapshot SHA-256: 594784982ac565dafd94abc0d6b0f5b520000febcd4c8adac9dca11eadd0c488; retrieved 2026-09-16T02:58:00.114Z.