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WPR19LA058 · Beech A36

7 Jan 2019 · Colusa, CA, United States

Beech A36 · Accident: loss of control in flight during initial climb

From Colusa County Airport (O08) to Palo Alto, CA

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Event

NTSB case
WPR19LA058
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
2 · 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
Instrument Meteorological Cond

Beech A36

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
N100JB
Operator
Unknown
Onboard fatalities
Unknown
Route
From Colusa County Airport (O08), Colusa, CATo Palo Alto, CA
Aircraft age
About 35 years (built 1984)
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
Initial climb
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
Loss of control in flight
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Destroyed

Cause areas

  • Personnel issues › Psychological
  • Personnel issues › Task performance

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

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.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record WPR19LA058
Event ID
20190108X15531
Case number
WPR19LA058
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: investigation status. Values present in the bulk record are kept.
  • The date is the local date, which is the same as the UTC date the NTSB stores.
  • API snapshot SHA-256: 825326c3e5fbf33bb14699a9877c6fa9a413b02694fd56becdb574d78948cc9a; retrieved 2026-09-15T06:52:50.006Z.