# NTSB ATL91LA055: Beech C23, N9146S, Concord, NC, February 14, 1991

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: February 14, 1991, 16:45 local (21:45 UTC)
- Place: Concord, NC
- Coordinates: 35.400604, -80.589942 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=35.4006&lon=-80.5899&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 2 uninjured
- Status: Completed, report March 31, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 8374
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL91LA055
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8374/pdf
- Page: https://openairdocs.org/ntsb/ATL91LA055

## Probable cause

THE PILOT'S INADEQUATE PREFLIGHT PLANNING IN THAT HE DISREGARDED THE CROSSWIND LIMIT IN THE PILOT'S OPERATING HANDBOOK.  FACTORS WERE THE WET RUNWAY AND THE RAVINE AT THE END OF THE RUNWAY.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- In flight encounter with weather, takeoff - initial climb
  - preflight planning/preparation - inadequate, pilot in command (cause)
  - performance data - disregarded, pilot in command (cause)
- On ground/water collision with object, landing - roll
- Overrun, takeoff - aborted
  - airport facilities,runway/landing area condition - wet (contributing factor)
  - terrain condition - ravine (contributing factor)
- Nose over, landing - roll

## Analysis

THE PILOT REPORTED THAT DURING TAKEOFF THE WIND SHIFTED FROM A HEADWIND TO A TAILWIND.  ONE WING DIPPED & THE AIRPLANE DESCENDED BACK INTO GROUND EFFECT.  THERE WERE TREES AT THE END OF THE RUNWAY SO, HE ELECTED TO ABORT.  THE GRASS/DIRT RUNWAY WAS WET.  A GROUND LOOP WAS ATTEMPTED BUT ACFT CONTINUED IN A STRAIGHT LINE, SIDEWAYS.  IT WAS REALIGNED WITH THE RUNWAY, ROLLED OFF THE END INTO A STREAM, & NOSED OVER.  A COLD FRONT HAD PASSED & WINDS WERE STRONG & GUSTY.  THE PILOT REPORTED THE WINDS BUT FAILED TO NOTE THE CROSSWIND LIMITS IN THE PILOT'S HANDBOOK.

## Aircraft

- Registration: [N9146S](https://openairdocs.org/deregistered/N9146S-1993-07-20), registration cancelled 1993-07-20, S/N M1769 (OpenAirDocs)
- Reported make and model: BEECH C23
- Registry model: [Beech C23](https://openairdocs.org/model/beech-c23) (registry code 1151242) (OpenAirDocs)
- Category: Airplane
- Serial number: M1769
- Engines: LYCOMING O-360-A4K 180 horsepower reciprocating
- Damage: Substantial damage
- Fire: In-Flight
- Flight: Personal, Part 91
- Operator: Dawson, John M.
- Airport: 4NC8, Goodnight Field, runway 33, 2,400 × 30 ft, grass/turf

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 35; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; flight hours: 356 total, 77 in this make and model, 246 as pilot in command, 8 in the last 90 days, 2 in the last 30 days

## Weather

- Conditions: Not reported
- Lowest ceiling: 8,000 ft broken
- Temperature: -0 °F, dew point -0 °F
- Observed at: CLT, 20 nm away

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 19910214003889A](https://openairdocs.org/incident/19910214003889A), Feb 14, 1991: Beech C23, Concord, NC, Substantial damage. Aborted takeoff. Beleived unable to climb over trees. Ran off end runway. Nosed over on the soft wet grass strip.

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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