# NTSB CEN20CA253: Beech 23, N18873, Davenport, IA, June 27, 2020 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 4 · Data collection · Final report - Date: June 27, 2020, 09:11 local (14:11 UTC) - Place: Davenport, IA - Coordinates: 41.612499, -90.588333 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.6125&lon=-90.5883&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Minor injuries - Injuries: 2 minor, 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Central Region - Parties: FAA Des Moines FSDO - NTSB case key (mKey): 101509 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20CA253 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101509/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101509 - Page: https://openairdocs.org/ntsb/CEN20CA253 ## Probable cause The pilot's failure to properly configure the airplane for takeoff, which resulted in the exceedance of the airplane's critical angle of attack, an aerodynamic stall, and subsequent impact with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech C23, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=1151242), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech C23, 23 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1151242), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Flight control system: elevator control system](https://openairdocs.org/ntsb-findings/01022730): Aircraft › Aircraft systems · Inadequate inspection (probable cause); cases with it: [Beech C23, 1 case](https://openairdocs.org/ntsb-findings/01022730/cases.md?model=1151242), [All aircraft, 74 cases](https://openairdocs.org/ntsb-findings/01022730/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Beech C23, 4 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=1151242), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Beech C23, 3 cases](https://openairdocs.org/ntsb-events/030/sequence.md?model=1151242), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Beech C23, 12 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1151242), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Beech C23, 8 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=1151242), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490); cases with it: [Beech C23, 4 cases](https://openairdocs.org/ntsb-events/490/sequence.md?model=1151242), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) ## Analysis The pilot was taking off and had begun to climb out when, the airplane's critical angle of attack was exceeded, an aerodynamic stall occurred, and the airplane impacted terrain. The airplane sustained substantial damage to the fuselage. A postaccident examination of the airframe by Federal Aviation Administration aviation safety inspectors found the trim was configured in a nose up setting for a landing profile. The pilot reported there were no preimpact mechanical malfunctions or failures with the airframe and engine that would have precluded normal operation. ## Factual narrative The pilot was taking off and had begun to climb out when the airplane's right wing dropped. The pilot responded by pushing the airplane's nose over but the wing struck the runway and the airplane subsequently impacted terrain causing substantial damage to the fuselage. A postaccident examination of the airframe by Federal Aviation Administration aviation safety inspectors found the airplane's elevator trim was configured in a nose up setting for a landing profile. The pilot reported there were no preimpact mechanical malfunctions or failures with the airframe and engine that would have precluded normal operation. ## Aircraft - Registration: [N18873](https://openairdocs.org/deregistered/N18873-2022-05-07), registration cancelled 2022-05-07, S/N M-1959, built 1977 (OpenAirDocs) - Reported make and model: Beech 23 (C23) - Registry model: [Beech C23](https://openairdocs.org/model/beech-c23) (registry code 1151242) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: M-1959 - Year built: 1977 - Airframe hours: 3426 - Engines: Lycoming Engines O-360-A4K 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 5, 2020 - Departed: DVN, Davenport, IA - Destination: DLL, Baraboo, WI - Airport: DVN, Davenport Muni, runway 03, 4,001 × 100 ft, concrete - Equipment: Stall warning system, Handheld GPS, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; injuries: minor; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review June 20, 2020; seat: left; restraint: none; flight hours: 145 total, 61 in this make and model, 32 as pilot in command, 45 in the last 90 days, 34 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Visibility: 10 statute miles - Temperature: 75 °F, dew point 70 °F - Altimeter: 29.86 inHg - Observed at: KDVN ## 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 20200627005819A](https://openairdocs.org/incident/20200627005819A), Jun 27, 2020: Beech C23, Davenport, IA, Substantial damage. Runway 03, immediately after take-off rotation, the aircraft pitched nose up and the right wing dropped, rolling the aircraft to the right into a nose down… ## Docket (2 files) The files NTSB released with the investigation on August 5, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101509. 686 KB in all. - Accident Photographs (item 1, .PDF, 582 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40485920&FileExtension=.PDF&FileName=Accident%20Photographs%20-Master.PDF - Record of Conversation - Federal Aviation Administration Aviation Safety Inspector (item 2, .PDF, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40485921&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Federal%20Aviation%20Administration%20Aviation%20Safety%20Inspector%20-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.