# NTSB CEN21LA208: Beech 23, N2378Z, Hutchinson, KS, May 1, 2021 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: May 1, 2021, 09:25 local (14:25 UTC) - Place: Hutchinson, KS - Coordinates: 38.066155, -97.86049 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.0662&lon=-97.8605&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Minor injuries - Injuries: 2 minor, 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Federal Aviation Administration; ICT FSDO - NTSB case key (mKey): 103030 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21LA208 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103030/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103030 - Page: https://openairdocs.org/ntsb/CEN21LA208 ## Probable cause The pilot’s failure to abort the takeoff and his high pitch attitude after takeoff, which resulted in an exceedance of the critical angle of attack and a subsequent aerodynamic stall. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: climb rate](https://openairdocs.org/ntsb-findings/01062035): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech 23, 1 case](https://openairdocs.org/ntsb-findings/01062035/cases.md?model=1151202), [All aircraft, 265 cases](https://openairdocs.org/ntsb-findings/01062035/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech 23, 2 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=1151202), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/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 23, 5 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1151202), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Beech 23, 2 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=1151202), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech 23, 7 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151202), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot stated that during takeoff on the 4,012-ft-long runway, the airplane seemed to accelerate slowly and use a greater amount of runway than normal. After liftoff, the airplane would not accelerate and climbed very slowly. The pilot turned the airplane toward the right, and it began to lose altitude. The airspeed decreased, and the airplane stalled about 20 to 30 ft above the ground. The airplane then impacted the ground. Postaccident examination of the airplane and engine did not reveal any mechanical anomalies that would have precluded normal operation. Takeoff performance data from the airplane’s flight manual showed that the airplane should have been about 50 ft above the ground when it was 2,281 ft down the runway. Given the length of the runway, the pilot had the opportunity to safely abort the takeoff when he realized that the airplane was not accelerating normally and not achieving its expected takeoff performance. However, the pilot continued the takeoff and likely raised the nose of the airplane to a high pitch and high drag attitude in an attempt to gain altitude. The high pitch attitude placed the airplane close to the critical angle of attack, and when the airplane entered a turn, it experienced an aerodynamic stall and descended to ground impact. ## Factual narrative On May 1, 2021, at 0925 central daylight time, a Beech 23, N2378Z, was involved in an accident near Hutchinson, Kansas. The airplane sustained substantial damage. The pilot and a passenger received minor injuries, and two passengers were uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, the purpose of the flight was to take two children for a ride as part of the Experimental Aircraft Association’s (EAA) Young Eagles program. The pilot stated that during takeoff on the 4,012-ft-long runway 17, the airplane seemed to accelerate slowly and use a greater amount of runway than normal. He rotated the airplane at 70 mph, and after liftoff, the airplane would not accelerate beyond 75 mph and climbed very slowly. The pilot turned the airplane toward the right, and the airplane began to descend. The airspeed decreased, and the airplane stalled about 20 to 30 ft above the ground. The airplane then impacted the ground resulting in substantial damage to the left wing. Postaccident examination of the airplane and engine did not reveal any mechanical anomalies that would have precluded normal operation. The pilot calculated that the takeoff weight of the airplane was 2,296 lbs. According to the airplane flight manual, at a takeoff weight of 2,300 lbs, a pressure altitude of 2,000 ft, a head wind of 0 knots, and an outside air temperature of 7o0 F, the ground roll and total takeoff distance to attain a 50 ft height were 1,316 ft and 2,281 ft, respectively. According to the EAA website, the EAA’s Young Eagles program was launched in 1992 and provides young people free introductory flights to introduce and inspire children in the world of aviation. The pilots participating in the Young Eagles program are local chapter members of EAA, who volunteer their time and aircraft. According to the EAA website, each pilot is licensed by the FAA (or a governing organization outside of the United States, such as Transport Canada), and all aircraft are likewise licensed by the government. The flights are conducted according to federal regulations. No aerobatic maneuvers are to be performed. The program is designed to use existing FAA oversight and requirements appropriate to a general aviation privately owned aircraft operation. ## Aircraft - Registration: [N2378Z](https://openairdocs.org/aircraft/N2378Z), registered now, S/N M-102, built 1962 (OpenAirDocs) - Reported make and model: BEECH 23 - Registry model: [Beech 23](https://openairdocs.org/model/beech-23) (registry code 1151202) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: M-102 - Year built: 1962 - Engines: Lycoming O320-DB2 reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Pilot - Registered owner: Pilot - Airworthiness certificate: Standard, Normal - Destination: Same as departure - Airport: HUT, Hutchinson Regional Airport, runway 17, 4,012 × 75 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: minor; private; airplane ratings: single-engine land; medical: basicmed; last flight review December 28, 2020; seat: left; restraint: lap only; flight hours: 184 total, 52 in this make and model, 86 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 13 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 64 °F, dew point 45 °F - Altimeter: 30.01 inHg - Observed at: HUT, 0.5 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 20210501009269A](https://openairdocs.org/incident/20210501009269A), May 1, 2021: Beech 23, Hutchinson, KS, Substantial damage. The pilot stated he continued a takeoff attempt after noticing the aircraft did not appear to be making full power due to sluggish performance. The plane had… ## Docket (6 files) The files NTSB released with the investigation on June 13, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103030. 7.4 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13588068&FileExtension=pdf&FileName=6120%20Master_Redacted-Rel.pdf - Pilot's weight and balance calculations (item 2, PDF, 1 page, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13600066&FileExtension=pdf&FileName=WB-Rel.pdf - Record of examination (item 3, PDF, 10 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13587212&FileExtension=pdf&FileName=Record%20of%20Examination-Rel.pdf - Record of correspondence - rlb (item 4, PDF, 1 page, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13598924&FileExtension=pdf&FileName=RECORD%20OF%20CORRESPONDENCE%20-%20RLB-Rel.pdf - Photo log (item 5, PDF, 1 page, 408 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13599644&FileExtension=pdf&FileName=Photo%20Log-Rel.pdf - Flight manual excerpt (item 6, PDF, 18 pages, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13600229&FileExtension=pdf&FileName=Flight%20Manual%20Excerpt-Rel.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.