Beech C23 N76SB accident near Midland, Virginia

Probable cause

The pilot’s decision to descend below the minimum decision altitude of the instrument approach without having the appropriate runway visual references distinctively identified and with the visibility and ceiling below the minimum that was prescribed for the approach, which resulted in controlled flight into terrain.

NTSB analysis

The pilot was on an instrument flight rules (IFR) flight and had performed several instrument approaches to two different airports near the departure airport. After performing the practice approaches, the pilot returned to his home airport to perform a final instrument approach and landing. The pilot reported to air traffic control (ATC) that he would cancel his IFR clearance after he descended below the cloud layer surrounding the airport. The pilot never made any emergency declarations to ATC throughout the flight. ADS-B data revealed that the airplane descended toward the runway, and track data was lost about 4,350 ft short of the runway and right of the runway centerline. A video surveillance camera captured the fireball of the impact, as well as audio, which indicated that the engine was operating at a high rpm just before impact.

The instrument approach the pilot attempted had a minimum decision altitude (MDA) between 384 and 424 ft above ground level (agl) at the airport; the exact MDA was dependent on the type of equipment the airplane had installed. The instrument approach also required 1 statute mile of visibility. The reported weather at the time of the accident had an overcast ceiling of 300 ft agl, which was below the MDA of the instrument approach. And while the latest reported visibility at the airport was 1.75 miles, the visibility from the surveillance camera was less than 1 mile. The camera visibility was below the minimum requirements for the instrument approach into the airport.

Postaccident examination revealed the airplane was destroyed by post-impact fire. Further examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation; the condition of the airplane’s navigational equipment could not be determined due to the extensive fire damage. However, before the accident, the pilot had successfully performed four other area navigation (RNAV) approaches in the local area, indicating the navigational equipment was working correctly during the accident flight.

The pilot’s toxicology results indicate he had used the sedating antihistamine medication diphenhydramine. The diphenhydramine level in postmortem iliac blood was low. While possible impairing effects related to diphenhydramine use cannot be entirely excluded, the toxicology results in this case provide no clear evidence that diphenhydramine effects contributed to the accident. The pilot’s elevated carboxyhemoglobin and the detection of cyanide in his blood can be attributed to effects of smoke inhalation during the post-crash fire, and do not constitute evidence of impairing pre-crash exposure.

Text from the NTSB. Open the NTSB docket for ERA24FA053 for the full record.