20191027018939A

Accident · Substantial damage

FAA accident report · Beech A36 · Leroy, NY · October 27, 2019

Date
October 27, 2019 · 15:03 local
Place
Leroy, NY
Airport
Le Roy
Phase of flight
Takeoff: Rotation
Operating rules
General operating rules (Part 91)
Damage
Substantial damage
Aircraft
N9008V
NTSB investigation
NTSBGAA20CA048
Reported as
Beech A36
Reported engine
Continental IO-520 series
People aboard
4
Fatal injuries
0
Other injuries
4
Pilot’s certificate
Private pilot
Pilot’s flight hours
285 total115 in this make and model11 in the last 90 days

From the FAA’s Accident/Incident Data System (AIDS), through its Aviation Safety Information Portal, as reported. The NTSB investigates accidents separately, and its record of an accident is the fuller one. The aircraft is matched to the registry by N-number and event date, checked against the reported make and model; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

What happened

The FAA’s narrative, in sentence case. The FAA writes it in capitals and removes private details.

Attempted takeoff from a paved runway/crashed in grass area at the end of the runway. Four occupants taken to hospital with unknown injuries. Flight originated @ 0930 CDT (evv), stopped at erie pa, stop @ (5G0), final planned stop @ (iua) NY. Pilot medical second class 12/12/2016. The pilot provided an FAA form 8700-2 basic med dated 2/18/2019. Proof of required medical class was not provided, (no medicial). The accident aircraft was configured with 5 seats. The FAA approved fm was in aircraft glove box. A non-approved checklist was found in the pilots seat. Valid registration was discovered. Damage assessment: substantial. Engine departed aircraft at firewall; right wing spar damage, landing gear and attach points damaged; vertical tail section substantially damaged; fuselage at vertical tail section, and middle of cabin section bent. Maintenance history: last airframe, engine, and prop annual inspection was accomplished at 12/08/18 by a+p/ia certificate ^#79548976^, cb aviation, inc. engine tach 1078.6, ttis 7547.7, smoh 0180.1. Fuel information: pilot stated 50 gallons 100LL on board, right tank was selected. Siphoned fuel from both tanks. There was 25+ gallons removed from left tank, and 22+ gallons removed from right tank. Fuel did not appear to have water in it. Weather 5G0 listed humidity 86%; wind speed w 23 g 35 mph; barometer 29.73 in (1006.7 mb); dewpoint 49F (9C); visibility 8.00 mi; wind chill 47F (8C); last update 27 oct 3:56 pm EDT. There was an additional national weather service wind warning posted for 3 miles e Leroy NY: urgent - weather message national weather service buffalo NY, 930 am EDT sun oct 27 2019,...wind advisory remains in effect until 6 pm EDT this evening. Southwest winds 25 to 35 mph with gusts up to 50 mph expected. 5G0 surveillance video caught last few seconds of the event. It depicted the aircraft at approximately 6 to 10 feet over west end of runway 28 at the numbers, followed by a sharp ~10 left bank followed by a sharp ~90 right bank, followed by close to level flight and the initial ground impact. Time stamp noted/additional cameras reviewed for wind indications. Video time stamp discovered wind sock to be straight out westerly winds with occasional southerly/southwesterly cross winds. Winds 23 knots gusting 35. Two skid marks were noted on the pavement at the end of the runway, nose tire and main. End of the runway lights not damaged. Initial ground impact approx. 155 feet west of end of pavement, (4258'53.68"n/ 7756'34.90"w). Aircraft hit nose gear first, low angle, then right main gear, appeared to collapse inwards. Flap switch was in up position, landing gear switch was in down position. Trim settings: elevator trim: indicated 6D. Point of interest #1: the bonanza-A36 normal takeoff checklist a non- FAA approved, was found loose in front cockpit area/stated: trim set a) aileron neutral; b) elevator 3 (6 if only front seats are occupied) accident aircraft trim was set 6D, four people on board. Point of interest #2: the non-approved check list found in cockpit, included: this check list is not to be used as a substitution for the owners manual. Point of interest #3: the non-approved check list was worded differently than FAA approved flight manual. The words, nose up, were not stated in the non-approved check list. Point of interest #4 aileron trim: the aileron trim selector appeared to be in the full right wing down position. Pilot stated he did not know what the ailreron trim was and never touched that. Interview revealed pilot had not had his flight review completed at the time of the accident. As required by 14 CFR 61.56

As the FAA filed it

ATTEMPTED TAKEOFF FROM A PAVED RUNWAY/CRASHED IN GRASS AREA AT THE END OF THE RUNWAY. FOUR OCCUPANTS TAKEN TO HOSPITAL WITH UNKNOWN INJURIES. FLIGHT ORIGINATED @ 0930 CDT (EVV), STOPPED AT ERIE PA, STOP @ (5G0), FINAL PLANNED STOP @ (IUA) NY. PILOT MEDICAL SECOND CLASS 12/12/2016. THE PILOT PROVIDED AN FAA FORM 8700-2 BASIC MED DATED 2/18/2019. PROOF OF REQUIRED MEDICAL CLASS WAS NOT PROVIDED, (NO MEDICIAL). THE ACCIDENT AIRCRAFT WAS CONFIGURED WITH 5 SEATS. THE FAA APPROVED FM WAS IN AIRCRAFT GLOVE BOX. A NON-APPROVED CHECKLIST WAS FOUND IN THE PILOTS SEAT. VALID REGISTRATION WAS DISCOVERED. DAMAGE ASSESSMENT: SUBSTANTIAL. ENGINE DEPARTED AIRCRAFT AT FIREWALL; RIGHT WING SPAR DAMAGE, LANDING GEAR AND ATTACH POINTS DAMAGED; VERTICAL TAIL SECTION SUBSTANTIALLY DAMAGED; FUSELAGE AT VERTICAL TAIL SECTION, AND MIDDLE OF CABIN SECTION BENT. MAINTENANCE HISTORY: LAST AIRFRAME, ENGINE, AND PROP ANNUAL INSPECTION WAS ACCOMPLISHED AT 12/08/18 BY A+P/IA CERTIFICATE ^#79548976^, CB AVIATION, INC. ENGINE TACH 1078.6, TTIS 7547.7, SMOH 0180.1. FUEL INFORMATION: PILOT STATED 50 GALLONS 100LL ON BOARD, RIGHT TANK WAS SELECTED. SIPHONED FUEL FROM BOTH TANKS. THERE WAS 25+ GALLONS REMOVED FROM LEFT TANK, AND 22+ GALLONS REMOVED FROM RIGHT TANK. FUEL DID NOT APPEAR TO HAVE WATER IN IT. WEATHER 5G0 LISTED HUMIDITY 86%; WIND SPEED W 23 G 35 MPH; BAROMETER 29.73 IN (1006.7 MB); DEWPOINT 49F (9C); VISIBILITY 8.00 MI; WIND CHILL 47F (8C); LAST UPDATE 27 OCT 3:56 PM EDT. THERE WAS AN ADDITIONAL NATIONAL WEATHER SERVICE WIND WARNING POSTED FOR 3 MILES E LEROY NY: URGENT - WEATHER MESSAGE NATIONAL WEATHER SERVICE BUFFALO NY, 930 AM EDT SUN OCT 27 2019,...WIND ADVISORY REMAINS IN EFFECT UNTIL 6 PM EDT THIS EVENING. SOUTHWEST WINDS 25 TO 35 MPH WITH GUSTS UP TO 50 MPH EXPECTED. 5G0 SURVEILLANCE VIDEO CAUGHT LAST FEW SECONDS OF THE EVENT. IT DEPICTED THE AIRCRAFT AT APPROXIMATELY 6 TO 10 FEET OVER WEST END OF RUNWAY 28 AT THE NUMBERS, FOLLOWED BY A SHARP ~10 LEFT BANK FOLLOWED BY A SHARP ~90 RIGHT BANK, FOLLOWED BY CLOSE TO LEVEL FLIGHT AND THE INITIAL GROUND IMPACT. TIME STAMP NOTED/ADDITIONAL CAMERAS REVIEWED FOR WIND INDICATIONS. VIDEO TIME STAMP DISCOVERED WIND SOCK TO BE STRAIGHT OUT WESTERLY WINDS WITH OCCASIONAL SOUTHERLY/SOUTHWESTERLY CROSS WINDS. WINDS 23 KNOTS GUSTING 35. TWO SKID MARKS WERE NOTED ON THE PAVEMENT AT THE END OF THE RUNWAY, NOSE TIRE AND MAIN. END OF THE RUNWAY LIGHTS NOT DAMAGED. INITIAL GROUND IMPACT APPROX. 155 FEET WEST OF END OF PAVEMENT, (4258'53.68"N/ 7756'34.90"W). AIRCRAFT HIT NOSE GEAR FIRST, LOW ANGLE, THEN RIGHT MAIN GEAR, APPEARED TO COLLAPSE INWARDS. FLAP SWITCH WAS IN UP POSITION, LANDING GEAR SWITCH WAS IN DOWN POSITION. TRIM SETTINGS: ELEVATOR TRIM: INDICATED 6D. POINT OF INTEREST #1: THE BONANZA-A36 NORMAL TAKEOFF CHECKLIST A NON- FAA APPROVED, WAS FOUND LOOSE IN FRONT COCKPIT AREA/STATED: TRIM SET A) AILERON NEUTRAL; B) ELEVATOR 3 (6 IF ONLY FRONT SEATS ARE OCCUPIED) ACCIDENT AIRCRAFT TRIM WAS SET 6D, FOUR PEOPLE ON BOARD. POINT OF INTEREST #2: THE NON-APPROVED CHECK LIST FOUND IN COCKPIT, INCLUDED: THIS CHECK LIST IS NOT TO BE USED AS A SUBSTITUTION FOR THE OWNERS MANUAL. POINT OF INTEREST #3: THE NON-APPROVED CHECK LIST WAS WORDED DIFFERENTLY THAN FAA APPROVED FLIGHT MANUAL. THE WORDS, NOSE UP, WERE NOT STATED IN THE NON-APPROVED CHECK LIST. POINT OF INTEREST #4 AILERON TRIM: THE AILERON TRIM SELECTOR APPEARED TO BE IN THE FULL RIGHT WING DOWN POSITION. PILOT STATED HE DID NOT KNOW WHAT THE AILRERON TRIM WAS AND NEVER TOUCHED THAT. INTERVIEW REVEALED PILOT HAD NOT HAD HIS FLIGHT REVIEW COMPLETED AT THE TIME OF THE ACCIDENT. AS REQUIRED BY 14 CFR 61.56

NTSB investigation

The NTSB’s investigation of this event, with its probable cause and findings. Matched to this report by N-number and date.

Other reports on N9008V · 1

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