Just before midnight on July 25, 1993, the owner of a Beechcraft F33A Bonanza, registration number N3022W, called the FAA to report that one of his airplanes, which he had lent to a friend a few days prior, was missing. That friend had flown the plane to a family reunion in Utah, taking as passengers his wife and an adult daughter. The light brown F-33, a mid-’70s straight tail Bonanza, departed from Camarillo Airport in Southern California on a Thursday on its way to a large family gathering in Roosevelt, Utah, a small town located in the eastern high country of Utah at an elevation of 5,000 feet.
As the reunion was wrapping up on Sunday, that same family trio boarded the Bonanza again for the return VFR trip to Camarillo. The summer weather was lovely.
In one of several unusual details that would later come out in the NSTB report, the pilot, a 54-year-old CFI/CFII with a couple of hundred hours in Bonanzas and Debonairs, telephoned the Camarillo Tower from Utah to tell personnel there of his planned return at 7 p.m. He alerted them that, “he might have a problem transmitting on his communications radios,” though there was no indication he had any trouble with the comm radios on the way to Utah three days earlier.
The pilot’s call about potential radio trouble didn’t serve as an official flight plan, so one can safely assume that when 7 p.m. came and went in Camarillo, tower personnel took no action. None was noted in the NTSB’s report.
As the evening wore on, a second daughter, who had stayed home in Southern California, phoned the owner of the plane to report that her family members had not returned home. The owner of the plane then called the FAA, twice, in fact—the first time to inquire about the plane’s whereabouts and the second time to report it missing.
That second call was the first official word to the FAA that the plane might be missing, and after it received that late call, the agency personnel issued a missing aircraft notice, which initiated the search process. The NTSB report doesn’t go into detail about the search process, but searchers likely began their hunt for the missing plane that next day, and the search almost certainly involved Civil Air Patrol aircraft and ground searchers. The search was just as likely abandoned after several days and having uncovered no trace of the plane. Its whereabouts would remain a mystery for months.
And just why the plane had gone missing was equally mysterious, though a disturbing detail did come to light in those first days. According to family members, a dozen of the attendees at the reunion had come down with an illness with food poisoning-like symptoms, though no one had needed to be hospitalized. There also had been no indication that the missing pilot had gotten sick or that the suspected food-borne illness was a factor in the Bonanza’s disappearance.
The missing plane’s location wasn’t a complete mystery. The pilot hadn’t filed a flight plan, and there was no record of communications with controllers along the way, but a radar track, wrote the NTSB investigator (in a strangely noncommittal way), “thought possibly to be the accident aircraft, was picked up by center radar and was tracked to within 3 miles of the crash site.”
Everything, in fact, pointed to the mystery radar track being that of the missing Bonanza. Its heading—southwest toward its destination on the Southern California coast—its ground speed (140 knots, ballpark for long-range cruise in the F33 with a likely 10-knot headwind component), and the place where it disappeared from radar, which was just 3 miles from the ultimately discovered crash site, are compelling evidence that the radar track was that of the missing Beechcraft. Still, such location data, even when radar data can narrow the search area, in this case, to around 10 square miles, an airplane can still be difficult or impossible for searchers to locate. When it’s a light brown-colored airplane in the light brown-colored desert, it’s even harder.
It would, in fact, be nine months before the plane’s wreckage was located in a sandy desert wash in a remote area of the California desert 20 miles north of Baker. Baker, which boasts the world’s tallest thermometer, is situated along an otherwise desolate stretch of U.S. 15, which runs from Southern California to Las Vegas, Nevada. Surrounding Baker are vast expanses of empty, rugged desert basin and range.
The plane might never have been found had it not been for a committed volunteer, a CAP ground searcher who had been involved in the original search and hadn’t given up hope of finding the plane.
Though there was an early witness, or at least she claimed, who knew just where the plane had crashed. A curious and extremely unusual note is included in the NTSB report, explaining that an unidentified woman had contacted the FAA a few days after the wreckage was found, claiming that she had witnessed the impact and had reported it right away, including, the report says, the precise location of the crash. A subsequent records search, the NTSB said, was unable to turn up a record of that first call or what, if anything, searchers had done with that information, or even whether it was accurate, or not.
Regardless, when the plane was physically located, investigators soon arrived on scene and began their process, and it would’ve been immediately clear to them that no one could have survived such an impact. The wreckage told a tale of a catastrophic, unsurvivably violent crash. The Bonanza hit the ground at a very steep angle, 75 degrees nose down and inverted, as well. A representative from the manufacturer estimated it hit at a speed of “between 230 and 240 knots,” or about 275 mph.
The plane was destroyed, and the report details the damage, noting, “Both main wings were separated from the fuselage with extensive leading edge crushing from root to tip. The ailerons and flaps separated from both wings. The vertical stabilizer and both horizontal stabilizers remained attached to the empennage, and all three leading edge surfaces exhibited extensive crushing.” Moreover, the landing gear separated from the aircraft and were found “beyond the initial ground scar.”
Reports that document an accident where an aircraft is located only after having been in the elements for a long time, as was the case with this Bonanza, often leave out specific mention of the occupants. In this case, the only word of their fates is that, “the certificated commercial pilots and his two passengers sustained fatal injuries.” One can safely presume that after eight months in a harsh desert environment, they would display little remaining meaningful or useful forensic evidence.
The report’s conclusion that the Bonanza crashed after a loss of control for unknown reasons at first glance reads like a non-conclusion, but it says more than one might think.
While the narrative of the report doesn’t come right out and say that there were no mechanical anomalies, it does eliminate as possible causes the most likely mechanical factors, along the way eliminating them one by one, such that the data summary spells it out, that “there was no evidence found to indicate a mechanical malfunction of the aircraft or its components.” The flight control surfaces, including counterweights, were accounted for, there was no sign of runaway trim, the engine was producing power and the propeller was turning when the plane hit the ground (not that engine power loss would account for the loss of control that preceded the impact).
There’s a mention of a forecast warning of moderate turbulence at the altitude the Bonanza was flying at. It’s a typical summer afternoon desert forecast, and, in practice, such turbulence is more of an annoyance than a hazard. The wreckage was found upwind of Kingston Peak, which at 7,335 feet elevation would have been a thousand feet below the presumed flight path of the Bonanza. Again, while the NTSB didn’t specifically rule out a weather event, it points to nothing that might make one think it gave such a cause much consideration.
The evidence it did uncover, that the seemingly mechanically sound plane went violently out of control for no apparent reason and with no apparent remedial action, points to a most likely cause—pilot incapacitation.
Is that indeed what happened? It’s impossible to say, and the report’s authors only suggest that possibility. But it’s that possibility and no others that are supported by the report.
Food poisoning is an unlikely cause. The report notes the suspected occurrence of food poisoning at the reunion the pilot had attended, though food-borne illnesses are seldom associated with sudden incapacitation, and there were numerous airports the flight had passed in the last half hour, two which the pilot could have diverted if he were in growing distress.
A sudden, massive heart attack would explain the accident, but there’s no strong evidence that the pilot had one. Fatal heart attacks are not uncommon among men in their mid-50s, and the pilot’s relatives did tell investigators that the pilot had both a family history of early heart disease and elevated cholesterol, but the pilot’s most recent FAA medical exam found him healthy with no issues noted.
Still, if the pilot had become incapacitated, it’s unlikely, the authors suggest, that the passenger in the right-hand seat could’ve done anything to prevent the tragedy that would ensue. The report points out that the plane was outfitted with a “throw-over yoke” and that neither of the passengers were certificated pilots.
For those who might not be familiar, this style of yoke has a single arm extending from a center push-pull tube, with a yoke at the end of the arm. Typically positioned in front of the front-left seat occupant, the entire mechanism can be swung over to the right side, allowing the control inputs to be made from what’s normally thought of as the co-pilot position. Moreover, the right-side position of many Bonanzas, including this one, is outfitted with retractable rudder pedals but no foot brakes.
The takeaway is, for a right-side passenger to quickly assume control of the plane, that passenger would need to be familiar with the mechanism and be able to execute the control swap-over. If the need to take control of the plane became clear only after the airplane had departed controlled flight, it would likely be a tall order indeed even for a pilot-rated passenger, let alone a non-pilot. Then, even after a successful repositioning of the throw-over yoke, the passenger turned pilot would have to be skilled enough to recover control of an aircraft that had already departed controlled flight.
Is that what happened? No one knows or will likely ever know. The NTSB didn’t make a true statement of probable cause, and it was right not to. There simply wasn’t enough evidence to support such a finding. But based on its report, which suggests much more than it could come right out and say, the major suspect was, and remains, pilot incapacitation and the horrifying chain of events that would almost certainly follow for the two occupants who weren’t incapacitated.
Such is the nature of accident investigations. Sometimes, having questions answered leads not to an understanding of why it happened but, instead, to an understanding of the terrible nature of what actually happened.
* * *
A Personal Connection
I have a personal link to the report that’s the subject of this month’s After The Accident. I didn’t know any of the victims of the crash, and my decision to write about this accident was based not on my connection to the story but to the compelling nature of it.
The NTSB’s thorough, methodical and professional investigation did as much as possible to help answer questions about a terrible tragedy, one that had taken three lives a year prior, a date that’s today more than 26 years in the past.
Losses like these affect many more lives than those who die in them or who survive them. I’m one of those people so affected, though my involvement was merely peripheral. I knew the actual airplane well.
That plane was a mid-1970s Bonanza—the report doesn’t specify its year, but I seem to recall that it was a 1975 model. The F-33 is a straight-tail version of the era’s ultimate four-seat piston single, and while it isn’t technically a Debonair, it’s a continuation of that same Beech Model 33. The model was later stretched to provide additional seating. The accident airplane was a four-seat version.
The plane’s owner was a former employer of mine, the owner of a number of aviation magazine titles and an avid warbird collector. He died in 2014. In addition to his warbirds, which included a North American B-25 bomber, he owned a few personal planes over the years, one of which was N3022W, the Bonanza that crashed on July 25, 1993.
At the time, I was in my early 30s and had been working for the aircraft owner as an aviation journalist along with my father, who, as some of you might know, was also an aviation journalist, as well as a pilot and an aviation business owner. At the time, I had been a pilot for more than a decade but was coming back to aviation as a low-time, rusty pilot.
The magazines I worked on were very low-budget affairs, but the owner was a true aviation lover and, much to our delight, generously supported our flying needs, which often meant lending us an airplane to fly. One of those airplanes was N3022W.
It was a great airplane, one in which I doubled my experience as a pilot. We flew it all around the country from our California desert home base, located about 90 miles southwest of the crash site. We had, in fact, flown the same route as the accident flight on more than one occasion. So I did have experience flying that particular airplane, which did indeed have a throw-over yoke and which also lacked toe brakes on the right side. When I flew with my colleague and instructor, we got to be pretty good at swapping the yoke over on a regular basis to give the other pilot a chance to do the flying. The process wasn’t difficult or lengthy in benign weather when in straight and level flight.
At some point, the aircraft owner asked us to return the Bonanza to Santa Monica, and he eventually gave us a different plane to fly, though at the time of the crash, we were briefly without an airplane. The reason he wanted the Bonanza back, he told us, was that he missed the airplane and wanted to fly it. He also said he had a friend who wanted to borrow it. That friend was the pilot of the plane featured in the NTSB accident report here.
I remember when we got the deeply upsetting report that N3022W was missing. We hoped for the best while tempering our optimism with the knowledge that when flights go missing, as this one had, the outcome is seldom a happy one, and the odds get slimmer with each passing hour.
After the search was called off, we all knew that the best we could hope for was that the plane would eventually be found, which would at least be an answer of some kind for the surviving family members.
When we heard the news many months later that the plane had been found, it did provide that answer, not one that anyone had hoped for, but one that we all had expected.
And I remember reading the accident report when it was first published, which was about a year after the plane went missing. It was deeply disturbing, as it laid out what had surely been a nightmare scenario.
It also cemented my commitment to be the safest pilot I could be and to do whatever I could in my career as an aviation journalist to help make flying safer for all. That’s a commitment I’ve been honoring as faithfully as I know how for more than 25 years and counting.