Monday, November 07, 2022

Beechcraft A36 Bonanza, N84R: Fatal accident occurred November 03, 2022 near Tucker-Guthrie Memorial Airport (I35), Harlan County, Kentucky

Dr. David George Sanford

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.

Investigator In Charge (IIC): Gerhardt, Adam

The National Transportation Safety Board traveled to the scene of this accident. 

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Louisville, Kentucky
Textron Aviation; Wichita, Kansas 

Location: Harlan, Kentucky
Accident Number: ERA23FA048
Date and Time: November 3, 2022, 10:09 Local
Registration: N84R
Aircraft: Beech A36 
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General aviation - Personal

On November 3, 2022, about 1009 eastern daylight time, a Beech A36 airplane, N84R, was destroyed when it impacted terrain at the Tucker-Guthrie Memorial Airport (I35) Harlan, Kentucky. The private pilot was fatally injured. The airplane was operated by the pilot as a personal flight conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

Review of preliminary Automatic Dependent Surveillance – Broadcast (ADS-B) data found that the airplane departed from Knoxville Downtown Island Airport (DKX), Knoxville, Tennessee, at 0932. The flight track continued northeast, and the airplane arrived into the I35 airport area about 1000. Subsequently, the flight track showed the airplane fly a tight left airport traffic pattern for runway 8. A total of three approaches were flown towards runway 8, with the final approach track ending at 1009:54 about .10 nautical mile from the runway 8 threshold.

Review of archived audio recordings of the I35 common traffic advisory frequency from found that as the pilot entered the traffic pattern area he stated, “Harlan tucker guthrie bonanza 84 romeo is two and a half to the west will circle for landing Harlan Tucker Guthrie.” There were no further radio communications recorded. The ADS-B flight track recorded around the I35 traffic pattern.

According to a pilot-rated witness that was at the I35 airport terminal, he heard what he believed to be the accident airplane complete two approaches to runway 8 about 1000. The witness never saw the airplane due to the visibility being severely restricted by morning fog. He characterized that the first approach seemed to be high, and the second approach sounded “really low”. For both passes the witness reported that the engine noise was a steady piston engine sound, with no noticeable change in power.

After the second pass, the engine sound became more distant, and he did not hear the accident airplane again, nor did he hear any sort of boom or the accident airplane’s eventual impact with terrain.

At the time of the accident, airport surveillance video showed fog that restricted visibility to about 175 ft.

The airplane impacted a ravine and steep rock wall about 50 ft below and 375 ft before the runway 8 threshold. All major portions of the airframe were located, and a post-crash fire consumed a majority of the cockpit, fuselage, and portions of the left wing. A drone image shows the view of the final approach to runway 8 and the disposition of the wreckage.

Flight control cable continuity was established from the elevator, rudder, and elevator trim tabs to the fire damaged forward cabin area. The left and right aileron control cable ends were identified in the forward cabin area and traced to the outboard wing areas where they were separated in tensile overload. Due to the impact and fire damage, the position of the flaps, landing gear, and fuel selector could not be determined.

The cockpit, switches, levers, and flight instruments were all severely damaged or entirely consumed by fire. It was not possible to obtain any instrument reading from the recovered instrumentation. The attitude indicator was disassembled, and its gyro and housing exhibited rotational scoring.

The engine had separated from its mount and the airframe. A large fracture hole was observed at the right forward area of the engine crankcase which was consistent with impact related damage. All propeller blades had separated from the propeller hub. Only one propeller blade was recovered at the accident site. The blade exhibited tip curling and leading edge gouging. All top spark plugs and lower Nos.1, 3, and 5 spark plugs when compared to the Champion Check-A-Plug chart, exhibited a worn out, normal to severe condition.

The oil filter when removed and examined displayed no evidence of debris or metal contaminants. Both magnetos produced spark when rotated by hand. The fuel manifold was safety wired and remained partially attached to the engine. When disassembled, its fuel filter screen was clear of debris and the manifold smelled of aviation gas. The engine could not be rotated by hand.

The vacuum pump remained attached to the engine accessory section. When the pump was partially disassembled, its gears were intact, and the unit appeared normal.

According to Federal Aviation Administration (FAA) airman records, the pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. He was issued a 3rd class medical certificate on November 9, 2015, where he reported a total flight time of 2,315 hours. He subsequently completed the FAA Basic Medical course on April 12, 2021.

According to preliminary FAA air traffic control (ATC) records, there was no known communication between the pilot and ATC, nor was there any flight plan opened or on-file for the accident flight.

At the time of the accident, a Notice to Air Mission (NOTAM) was in effect noting that all airport lighting was unserviceable (out of service).

The wreckage was retained for further examination.

Aircraft and Owner/Operator Information

Aircraft Make: Beech
Registration: N84R
Model/Series: A36 
Aircraft Category: Airplane
Amateur Built:
Operator: On file
Operating Certificate(s) Held: None
Operator Designator Code:

Meteorological Information and Flight Plan

Conditions at Accident Site: IMC
Condition of Light: Day
Observation Facility, Elevation: I35, 1552 ft msl
Observation Time: 10:15 Local
Distance from Accident Site: 0 Nautical Miles
Temperature/Dew Point: 8°C /8°C
Lowest Cloud Condition: 200 ft AGL
Wind Speed/Gusts, Direction: / ,
Lowest Ceiling: Overcast / 200 ft AGL 
Visibility: 0 miles
Altimeter Setting: 30.37 inches Hg
Type of Flight Plan Filed: None
Departure Point: Knoxville, TN (DKX) 
Destination: Harlan, KY (I35)

Wreckage and Impact Information

Crew Injuries: 1 Fatal 
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: On-ground
Ground Injuries: N/A
Aircraft Explosion: On-ground
Total Injuries: 1 Fatal
Latitude, Longitude: 36.857933,-83.365427 

Those who may have information that might be relevant to the National Transportation Safety Board (NTSB) investigation may contact them by email, and any friends and family who want to contact investigators about the accident should email You can also call the NTSB Response Operations Center at 844-373-9922 or 202-314-6290.

Dr. David George Sanford
October 26, 1967 ~ November 3, 2022 (age 55)

David George Sanford, 55, passed away Thursday, November 3, 2022. He was born October 26, 1967, in Knoxville, Tennessee, to the late Georgia Sharp Baker and Charles Sanford and he was also the stepson of the late James Baker. He is survived by his beloved wife and children, Amy, George, and Mira all of Knoxville, Tennessee; a sister, Lisa (JD) Sanford Howard of Knoxville, Tennessee; a special aunt, Jessie Malin of Rector, Arkansas; a sister-in-law, Alice (Mark) Elkins of Middlesboro, Kentucky; and his in-laws, Judy and Dewey England of Harrogate, Tennessee. His niece and nephews, Collier Elkins, Caroline Elkins, Luke Howard, and Robert and Daniel Hall also survive him. His brother, Alan Sanford, preceded him in death. David leaves behind a devasted host of relatives, friends, and colleagues.

David was a graduate of Middlesboro High School, Lincoln Memorial University, and the University of Kentucky College of Medicine. After completing his internship at St Vincent Hospital in Indianapolis, Indiana, and ophthalmological residency at the UK Chandler Hospital in Lexington, Kentucky, he came home to the mountains to open his practice. For twenty-five years he cared for patients in Middlesboro, Harlan, and throughout the region. Dr. Sanford relished both the privilege and opportunity to make a difference in the lives of his patients by helping them to see better. He was known not only for his skill as a surgeon but for his humility, kindness, and his terrific sense of humor. “Wherever the art of medicine is loved, there is also a love of humanity.” ― Hippocrates

David grew up in Middlesboro, Kentucky, where he met and married Amy. In the decade before George and Mira were born, David and Amy traveled and worked together while anxiously awaiting the day when they would become parents. David loved a hobby and throughout his life he passionately pursued piano, guitar, radio DJing, flying, dirt bike riding, running, hiking, and tennis. With every venture he assembled a fellowship of enthusiasts whose comraderie and friendship sustained him. His greatest joy was watching George and Mira grow and develop their own passions. From swimming and lacrosse to cross country, Lego, and video games, if his kids wanted to try it, he was all in. David was also a thoughtful and committed longtime member of the recovery community.

David’s funeral will be held at Sevier Heights Church on Sunday, November 13, 2022 at 3:30 pm.

In lieu of flowers, please make donations to Violet’s Village at or to Steps House Inc at

This obituary is a courtesy to the family of Dr. David George Sanford by the Anderson-Laws & Jones Funeral Home of Harlan. 

Aircraft struck a cliff while attempting to land on runway. 

Date: 03-NOV-22
Time: 14:15:00Z
Regis#: N84R
Aircraft Make: BEECH
Aircraft Model: 36
Event Type: ACCIDENT
Highest Injury: FATAL
Total Fatal: 1
Flight Crew: 1
Pax: 0
Aircraft Missing: No
Activity: PERSONAL
Flight Phase: APPROACH (APR)
Operation: 91

Kentucky State Police secure the scene following the crash of a small airplane at Tucker-Guthrie Memorial Airport on Thursday, November 3, 2022.

Harlan County, Kentucky -  A single-engine airplane crashed on Thursday near Tucker-Guthrie Memorial Airport in Harlan, resulting in the death of one individual.

According to Harlan County Deputy Coroner Jim Rich, Dr. David Sanford, 55, died as a result of a plane crash near Tucker-Guthrie Memorial Airport in Harlan on Thursday.

According to Kentucky State Police Public Relations Officer Shane Jacobs, KSP Post 10, Harlan, was notified of the incident on Thursday morning.

“At approximately 10 a.m., Post 10, Harlan received multiple calls in reference to a loud noise,” Jacobs said. “A short time later, a small plane was discovered crashed just south of the airport.”

Jacobs confirmed there were no known survivors of the crash, with one fatality verified as of approximately 12:30 p.m. on Thursday.

KSP Det. Andy Soltess is in charge of the death investigation. The FAA will investigate the cause of the crash

The Harlan County Rescue Squad, the Harlan City Fire Department, and Sunshine Fire Department responded to the scene.


  1. Looks like a go around and then a crash? The weather may have been appropriately IMC.

    1. Almost looks like he entered a holding pattern, but I agree a go around is more likely.

  2. appears base was KNOXVILLE, TN with frequent flights into rural KY, including Tucker-Guthrie Memorial Airport (I35), Harlan County, Kentucky.
    Observed at 09:55 UTC on the 3rd
    Reporting station AUTO
    Calm wind
    Visibility of 0.25 statute miles
    Overcast clouds at 200 feet
    Temperature 8˚C and dewpoint 8˚C
    Pressure: 30.31inHg (1026mb)
    Remarks follow
    Automated site with precipitation descriminator
    Precision temperature 7.7˚C and dewpoint 7.7˚C

    1. That's HARD IMC. 200 ft is right at minimums for an ILS or RNAV assuming the aircraft was equipped and the pilot was current.
      Not sure about his personal minimums but I would never do a weather at minimums on a precision approach in a small plane, unless a TAA with a solid and reliable autopilot. And I own a skychicken with just one VOR (but still IFR) so you won't see me if it's below 900 anytime soon.

    2. Very much below minimums. That airport only has one approach - an RNAV with circling-only minimums (10° offset and 3.77° glidepath). The MDA is 2920 (1356 HAA) for cats A and B (1-1/4 and 1-1/2 miles min visibility, respectively). The airport is in a fairly tight valley.

      Assuming the data are correct, it looks like he was fishing around for the runway well below the MDA.

    3. "Hollers are most often found in Eastern Kentucky where the land is thick with small mountains which allow for the many narrow valleys. Further west in the Pennyrile area and Knobs area they are called Hollows and are usually wider than in the eastern part of the state."

    4. Thank you for sharing that - a bright spot in an otherwise dismal accident report.

  3. according to the flight tracking, it looks like maybe he had executed 2 missed approaches followed by a full procedure back in

    1. None of those were the published missed approach, not by a longshot. It was an attempt to continue circling and scud run it in, despite the reported weather and published minimums having zero chance of allowing that to be accomplished legally and safely. Now, if the weather report was stale and flight data incorrect (there are some weird anomalies as pointed out elsewhere), then bets are off. But at first glance it looks like a botched attempt to circle.

    2. According to METAR history, half hour after accident vis was 10 and sky was CLR.


    3. please post ur "According to METAR history, half hour after accident vis was 10 and sky was CLR. "

    4. The poster of the 10SM comment is correct.
      KI35 Data file (linked below) shows:
      MET08711/03/22 09:55:02 METAR KI35 031455Z 00000KT 1/2SM OVC002 09/09 A3035 RMK AO2 T00930093
      MET08611/03/22 10:15:02 METAR KI35 031515Z 00000KT 10SM SCT002 10/10 A3035 RMK AO2 T01030103
      MET08311/03/22 10:35:02 METAR KI35 031535Z 00000KT 10SM CLR 12/12 A3035 RMK AO2 T01180116

      See Row 21154-21156 Column Y after downloading:

      How to retrieve this historical data:
      - Select date of accident
      - Enter airport NAME, pick from pulldown
      - See data file in results

    5. Applicable pre-crash METAR is 1355Z, not 1455Z for the 14:15:00Z crash time in the report header (Notice that FR24 data ends @14:09Z)

      Let's add those METARs from the .csv file:
      MET08811/03/22 08:55:02 METAR KI35 031355Z 00000KT M1/4SM OVC002 08/08 A3036 RMK AO2 T00810081
      MET08811/03/22 09:15:02 METAR KI35 031415Z 00000KT M1/4SM OVC002 08/08 A3037 RMK AO2 T00820082
      MET08811/03/22 09:35:02 METAR KI35 031435Z 00000KT M1/4SM OVC002 09/09 A3036 RMK AO2 T00860086

      Discussion wasn't looking at the correct METAR for the time of crash, and turns out it wasn't clear and ten miles visibility 30 minutes later.

    6. No body said it was clear at the time of the crash. I think the point being made was shortly after the crash the weather had cleared up. Had he only waited for an extra hour or so, we likely wouldn't be having this discussion.

    7. The request to post METARs for afterwards resulted in real data that revealed the true time interval from crash to clear sky. Knowing that the interval was about 1.5 hours dispels the notion that the pilot just needed to circle the field a bit longer than he did.

    8. From the preliminary report - "According to preliminary FAA air traffic control (ATC) records, there was no known communication between the pilot and ATC, nor was there any flight plan opened or on-file for
      the accident flight"

      He wasn't on an IFR flight plan and he went looking for the airport. It looks like he went looking 3 times and on the last attempt he"landed" at the base of the runway. There's a photo in the report, the end of the runway ends in a small "cliff" and he smacked into the wall.

  4. Look at the altitudes on flight tracking -- above 12,000 feet the whole time. Something was wrong with the altitude reporting.

    1. Same error in ADS-B reported altitude as the day before the accident when he flew from KI35---->KDKX. His October 28 flight didn't have that big offset error in the ADS-B altitude. Maybe he had one of those cheap ADS-B encoders installed in place of a marker light and it was acting up.

      Wonder if the controllers at nearby McGhee Tyson Airport noticed the erroneous altitude reporting on 2 or 3 November, and whether he set out on the accident day knowing about it.

    2. Wonky altitude reporting also evident on 1 November:

  5. Per what is described above the whole approach to the airport was illegal to begin with: IMC and no IFR procedure to get in by a long shot.
    Was he even instrument rated? Looks like scud running of a VFR only pilot that somehow went into IMC. The preliminary might be interesting on that one.
    Regardless we can say a few rules written in blood were broken just by casually looking at the flight track and airport characteristics. Unless it was an emergency but this is stretching it as the question to ask was what he was doing in the air in hard IMC to begin with?

    1. According to FAA pilot certificates he was instrument rated.

      Certificate: PRIVATE PILOT
      Date of Issue: 12/17/2015



    2. he had patients and surgeries scheduled that day and did not want to disappoint his patients by cancelling the flight and then rescheduling the patients to a later date

    3. Then he should have gotten in his car. It's a 2 hour and 10 minute drive (104 miles) from Knoxville to Harlan. Door-to-door you save one hour -- at the most -- by flying in a Bonanza versus driving in a car.

    4. I always use the 90-minute rule as a break-even. However, if you factor in risk (like marginal weather), it’s not worth the minuscule time saved, out to a much larger margin than the break-even.

    5. Not having to drive long distances on winding and mostly two lane roads can be a bigger consideration than time savings. Flying precluded puttering behind slow traffic in long stretches of double yellow line waiting to reach a truck passing lane or the inevitable close calls during white knuckle passing runs.

      Flew on a day he should have driven, but road trips on those routes to the clinics weren't low risk limited access interstate highway exit to exit runs.

    6. Which is why I based it on time, not distance. That said, if your driving route adds significantly additional distance over straight-line, such as in the mountains, then there is something to say for that.

    7. Instrument rated pilot flies multiple low altitude passes over a field with 200 ft overcast, with no apparent correlation to the only non-precision approach, eventually killing himself in the process.

      Does anyone sense one or more hazardous attitudes in play here? This is sad and all too often repeated story.

    8. Added to the question of attitude is the malfunctioning ADS-B altitude reporting. Had he been made aware of it during the Nov 1 & 2 flights but continued to add flight days without getting that repaired?

      Potential for a mid-air collision with another aircraft whose ADS-B in display showed N84R's altitude 10K feet higher than true wasn't trivial.

    9. Everyone is in such a damn hurry. This looks like a pure case of "get there-ite-us". Any Time saved is pointless if you end up not making it to your destination.

      When on a highway don't get stressed you aren't driving as fast as you want, tailgating doesn't make people drive faster and just puts both of you into an unsafe situation completely at the whim of the following driver, all for the savings of a minute or two over the journey.

  6. Airport elevation is 1564. The only instrument approach is RNAV (GPS)-A, a circling approach with minimums of 2920 (1400 feet above airport elevation) and 1 1/4 miles of visibility. Disregarding the ADS-B altitude reporting and simply looking at his flight track, it looks like he went missed twice and was trying a third time when he crashed. Assuming the weather as reported at 1355Z (cited in an anonymous comment above) is correct, he was not just way below minimums, he completely disregarded them. Because he crashed into a cliff below the runway elevation, he was more than 1200 feet (!) lower and in visibility a full mile (!) lower than minimums. It sure looks like a severe case of gethereitis.

    1. Going missed is being generous. The FAF, JEXIL is somewhere between small towns Molus and Coldiron on the map, and the missed approach hold is a further 5.5nm away from the airport. After crossing JEXIL, the a/c never goes anywhere near even JEXIL again.

      If I had to guess, he was either glimpsing the ground through a broken layer or making up his own return loops, trying to get lined up with the runway again. Except maybe for the first pass over the runway, he was not following published approach at all.

  7. I found some audio on live for the CTAF at I35. N84R makes one announcement, "2-1/2 to the west, will circle to land". Only that single transmission. It's towards the end of the archive recording that starts at 13:30Z. There's nothing on the archive recording starting at 14:00Z.

    I could not find an audio feed for Indy Center (124.625) on live, so no idea if there was any flight following or a flight plan of any kind active.

  8. They pulled the flight history from flight radar 24. It was a great depiction of the 3 attempts.

    1. FR24 links are available for 7 days without subscribing. The history wasn't pulled, it just timed out and went behind the subscription paywall.

  9. numerous aerial approach views to Tucker-Guthrie Memorial Airport @!1s0x885b44748dc7bee9%3A0x89138df79a32e589!3m1!7e115!!5sTucker-Guthrie%20Memorial%20Airport%20on%203D%20-%20Google%20Search!15sCgIgAQ&imagekey=!1e10!2sAF1QipNISECy72Shlx9avE23KoZA1X7_tNYmhImS8_J2&hl=en&sa=X&ved=2ahUKEwiP0_2TiaT7AhXMkIkEHbvYD1oQoip6BAhdEAM

    1. It would not surprise me if that area is subjected to "micro-climates" on an almost daily basis. The usual daily fog might be "burned off" sometime before noon from a late rising sun obscured by hills and trees.

    2. Timing of the morning burn off that cleared up KI35 100 foot broken on the day prior to the accident should have provided a useful planning reference point before launching on the accident day.

      Burn off would be expected to complete much later in the morning to clear up the socked in conditions of the accident day. (METARs showed the KI35 00000KT 1/4SM OVC002 08/08 conditions present for several hours straight before the decision was made to launch from Knoxville).

      METARs on the day prior to the accident, for reference:
      KI35 021235Z 00000KT 1 1/4SM BKN001 OVC120 09/09 A3033
      KI35 021255Z 06004KT 1 3/4SM BKN001 OVC120 09/09 A3033
      KI35 021315Z 00000KT 7SM SCT001 SCT120 09/09 A3034
      KI35 021335Z 00000KT 7SM CLR 10/10 A3034
      KI35 021355Z 00000KT 7SM CLR 10/10 A3035
      KI35 021415Z 00000KT 10SM CLR 11/11 A3035
      KI35 021435Z 00000KT 10SM CLR 11/11 A3033

    3. at first glance you would think that metar was a joke to actually try that non-precision approach without an alternate

  10. Very sad. In carrier aviation, this would have been described as a massive ramp strike.

  11. An accident waiting to happen?

    Interesting read in Air Facts Journal about this accident and the flights the pilot regularly made from someone who knew the pilot to regularly fly when weather was unfavorable and below the minimums. Like the article is titled, this was just and "Accident waiting to happen"

    1. The author of the airfactsjournal article thought the Doc's landings at Tucker were diversions from Middlesboro. They weren't.

      Disappointing to see someone who didn't bother to look up the multiple clinic locations mischaracterize the planned destination as a divert. The Doc made a bad decision on the accident day, but none of the recurring flights into Tucker were diverts from Middlesboro.

  12. Crap weather and only circling minimums into that airport. Other comments relating to the "Air Facts Journal" reporting about the pilot routinely flying in weather below mins. The minimums and the regs are there for good reasons and a lot of the regs are written in blood. And the minimums are the MINIMUMS. Single pilot, single engine, potentially hazardous terrain? Add a few hundred feet to MDA and have enough fuel to divert.

    Another doctor in a Bonanza adding to the "Doctor In A Bonanza" statistics.....

  13. The approach is pretty straightford. Based on ADSB data he didn't need to and didn't enter the hold at the IAF (WEVOR, 11.6 miles from missed approach point and just before the town of Galloway). In fact, it looks like he didn't fly to the IAF or FAF at all. He appears to have proceeded to something other than the FAF (JEXIL, 6.1 miles from the MAP, and between Molus and Coldiron). He passed north of JEXIL. The MAP (ECGIG) is offset 10 degrees from the final approach course. As already noted, the altitude reported is completely jacked up. The airport is at 2,564' msl. There are peaks at 2,828' and 3,278' along the tracks that look sort of like procedure turns. The approach ends at the MAP and 2,920-1-1/4. 356' AGL.

    instrument rated pilot. Currency is unknown. No IFR flight plan. He's flown into the airport a lot. He made 3 attempts to get in. Conditions were below minimums. On the 3rd attempt he was at 100 kts, 50' - 100' ish below the threshold which just happens to be a vertical wall of stone (just guessing how low he was based on the photograph of the crash site)

    Aside from poor judgement and a clear violation of the regs it might have been a small altimeter setting error that did him in. It looks like he flew there almost daily.

    1. Correction, 1,356' not 356'. Commas matter...

    2. Not knowing the tops of the fog layer, he could have been VFR on top while circling back for another attempt to land, each time going lower into the fog in hopes of seeing the runway.

    3. Weather wasn't just "below minimums" for a non-precision approach -- it was at or below minimums for even an ILS approach (excepting CAT-II or CAT-III), which didn't exist.

      What did him in was not a small altimeter error, but a flagrant disregard for regulations, his safety, and most likely an attitude of invincibility. If this one didn't get him, another one would have.

  14. HAPPY THANKSGIVING everybody! May all your landings be gentle.

    1. Gracias. I'm an instrument student. We don't have gentle landings :) We have holy sh*t the runway is RIGHT THERE. : ) Chop the power, dump the flaps or TOGA landings. I'm almost looking forward to my first post instrument rating VFR landing. Almost... Instrument training has been the best flying time of my life. But I am looking forward to a nice simple base to final turn and approach to landing...

  15. I'm reading Rinker Buck's 'Flight of Passage.' Good read, he and his bother's 1965 six day NJ to CA flight in their 85 horsepower Piper Cub.... a flight with original panel and no radio.

    1. Have you read Stick and Rudder ?