# NTSB CEN16CA359: Beech 58, N15MD, Wichita Falls, TX, August 26, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: August 26, 2016, 08:50 local (13:50 UTC) - Place: Wichita Falls, TX - Coordinates: 33.988887, -98.491943 - Nearby events: https://openairdocs.org/map.md?lat=33.9889&lon=-98.4919&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report December 5, 2016 - Report: Approved by Office Director - NTSB office: Central Region - NTSB case key (mKey): 93969 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN16CA359 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93969/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93969 - Page: https://openairdocs.org/ntsb/CEN16CA359 ## Probable cause The incorrect maintenance of the airplane's ventilation system which resulted in an obstruction of the elevator control system. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Flight control system: elevator control system](https://openairdocs.org/ntsb-findings/01022730): Aircraft › Aircraft systems · Inoperative (probable cause); cases with it: [Beech 58, 1 case](https://openairdocs.org/ntsb-findings/01022730/cases.md?model=1152740), [All aircraft, 74 cases](https://openairdocs.org/ntsb-findings/01022730/cases.md) - [Air conditioning system: air distribution system](https://openairdocs.org/ntsb-findings/01022120): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Beech 58, 1 case](https://openairdocs.org/ntsb-findings/01022120/cases.md?model=1152740), [All aircraft, 2 cases](https://openairdocs.org/ntsb-findings/01022120/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) (defining event); cases with it: [Beech 58, 2 cases](https://openairdocs.org/ntsb-events/333/sequence.md?model=1152740), [All aircraft, 410 cases](https://openairdocs.org/ntsb-events/333/sequence.md) - [Takeoff-rejected takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech 58, 19 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1152740), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that, during a maintenance test flight, when the airplane reached rotation speed on takeoff, he applied elevator control to rotate. The elevator control could not be moved sufficiently aft for rotation and liftoff, and the pilot aborted the takeoff. During the aborted takeoff, the airplane travelled off the departure end of the runway and came to a stop on an airport access road. The airplane's left main landing gear collapsed and the left wing was bent during the accident. The pilot reported that he had performed a control system check prior to the flight and that the controls functioned normally during that check. Examination of the airplane revealed that the elevator control operated normally after the accident, but further examination revealed that a plastic elbow fitting for the windshield defroster duct was loose and could be rotated into a position that obstructed full motion of the control yoke. Examination of the elbow revealed that it was not an approved part and appeared to be the type of plastic elbow found in home supply stores. The recent maintenance performed was not in the area where the plastic elbow was located. ## Factual narrative The pilot reported that, during a maintenance test flight, when the airplane reached rotation speed on takeoff, he applied elevator control to rotate. The elevator control could not be moved sufficiently aft for rotation and liftoff, and the pilot aborted the takeoff. During the aborted takeoff, the airplane travelled off the departure end of the runway and came to a stop on an airport access road. The airplane's left main landing gear collapsed and the left wing was bent during the accident. The pilot reported that he had performed a control system check prior to the flight and that the controls functioned normally during that check. Examination of the airplane revealed that the elevator control operated normally after the accident, but further examination revealed that a plastic elbow fitting for the windshield defroster duct was loose and could be rotated into a position that obstructed full motion of the control yoke. Examination of the elbow revealed that it was not an approved part and appeared to be the type of plastic elbow found in home supply stores. The recent maintenance performed was not in the area where the plastic elbow was located. ## Aircraft - Registration: [N15MD](https://openairdocs.org/deregistered/N15MD-2018-06-15), registration cancelled 2018-06-15, S/N TH-441, built 1974 (OpenAirDocs) - Reported make and model: BEECH 58 (UNDESIGNAT) - Registry model: [Beech 58](https://openairdocs.org/model/beech-58) (registry code 1152740) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TH-441 - Year built: 1974 - Airframe hours: 7676 - Engines: CONT MOTOR IO 520 SERIES 285 horsepower reciprocating; CONT MOTOR IO 520 SERIES 285 horsepower reciprocating - Damage: Substantial damage - Flight: Flight test, Part 91 - Operator: Cobra Kai Flight Academy - Registered owner: Cobra Kai, Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 4, 2016 - Departed: CWC, Wichita Falls, TX - Destination: CWC, Wichita Falls, TX - Airport: CWC, Kickapoo Downtown, runway 17, 4,450 × 75 ft, concrete - Equipment: Stall warning system, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; injuries: none; flight instructor, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; seat: left; restraint: 3-point; flight hours: 4,507 total, 423 in this make and model, 4,004 as pilot in command, 130 in the last 90 days, 38 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 120° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 68 °F - Altimeter: 30.06 inHg - Observed at: CWC ## 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 20160826020449A](https://openairdocs.org/incident/20160826020449A), Aug 26, 2016: Beech 58, Wichita Falls, TX, Substantial damage. 1) Description of deviation: after a normal preflight and run-up the pilot started a takeoff run which was aborted at rotation when the pilot sensed a jam in… ## Docket (2 files) The files NTSB released with the investigation on October 25, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93969. 3.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40445655&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Excerpt from Illustrated Parts Catalog (item 2, .PDF, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40445656&FileExtension=.PDF&FileName=Excerpt%20from%20Illustrated%20Parts%20Catalog-Master.PDF 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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.