# NTSB CEN22FA031: Britten-Norman BN-2A, N866JA, Beaver Island, MI, November 13, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: November 13, 2021, 13:49 local (18:49 UTC) - Place: Beaver Island, MI - Coordinates: 45.719909, -85.517729 - Nearby events: https://openairdocs.org/map.md?lat=45.7199&lon=-85.5177&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 4 fatal, 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Hartzell Propeller, FAA/Federal Aviation, Lycoming Engines, Air Accidents Investigation Branch - NTSB case key (mKey): 104239 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22FA031 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104239/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104239 - Page: https://openairdocs.org/ntsb/CEN22FA031 ## Probable cause The pilot's exceedance of the airplane's critical angle of attack during final approach, which resulted in an aerodynamic stall and loss of control at an altitude too low to recover. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Britten-Norman BN-2A, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=1520204), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/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: [Britten-Norman BN-2A, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=1520204), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Britten-Norman BN-2A, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1520204), [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. - [Approach-VFR pattern final: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Britten-Norman BN-2A, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=1520204), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) ## Analysis A pilot-rated witness observed the airplane during the final approach to the destination airport and stated that the airplane was flying slowly, with a high pitch attitude, and was “wallowing” as if nobody was flying. The airplane stalled and impacted the ground about 300 ft from the runway. GPS and automatic dependent surveillance-broadcast (ADS-B) data captured the accident flight, but the ADS-B data ended about 0.24 miles before the accident. GPS data showed that the airplane’s speed was at or near the published stall speed for the airplane’s given loading condition. The airplane sustained substantial damage to the fuselage and both wings. Examination of the airplane verified flight and engine control continuity. No preimpact anomalies were found with respect to the airplane, engines, or systems. The pilot allowed the airspeed to decrease during the approach, increased pitch attitude, and exceeded critical angle of attack, which resulted in an aerodynamic stall and spin into terrain. ## Factual narrative The airplane was a twin-engine, high-wing, strut-braced monoplane with a fixed tricycle landing gear arrangement. It was configured to accommodate 10 people, including the flight crew, with additional baggage capacity behind the passenger seats. The airplane load manifest indicated that the airplane was operating at a weight of 5,903 lbs., and the center of gravity was at 25.3 inches aft of the datum, within the manufacturer’s prescribed weight and center of gravity limits. According to the operator, all passengers and baggage were weighed on a scale before flight. According to the airplane flight manual, for a weight of 6,000 lbs. with flaps down, the stall speed was listed as 42 knots (48 mph). On November 13, 2021, at 1349 eastern standard time, a Britten Norman BN-2A airplane, N866JA, was substantially damaged when it was involved in an accident near Beaver Island, Michigan. The pilot and three passengers were fatally injured, and one passenger received serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 135 air taxi flight. The ADS-B data showed that the airplane departed Charlevoix Municipal Airport (CVX), Charlevoix, Michigan, at 1332. After departing CVX, the airplane turned north and proceeded directly toward Welke Airport (6Y8), Beaver Island, Michigan. The enroute portion of the flight was conducted about 1,500 ft above mean sea level (msl), and the airplane remained at this altitude until it was about 3 nautical miles (nm) from 6Y8. At this point, the airplane descended and maneuvered toward a straight-in approach to runway 35 at 6Y8. The ADS-B data ended about 0.24 nm south of the accident site. The track data from a handheld GPS that was used in the airplane coincided with the ADS-B data but recorded additional data that ended at the accident site. Figure 1: Overview of the accident flight. ADS-B flight track depicted in blue, GPS flight track depicted in red. Figure 2: Plot of ADS-B and GPS flight track data for the final portion of the accident flight. ADS-B data depicted in blue. GPS data depicted in red. The GPS recorded position, heading, altitude, and ground speed among other data. The airplane’s airspeed was calculated from the GPS groundspeed considering the recorded winds at the Beaver Island Airport (SJX), located about 2 nm southwest of the accident site. When the airplane was 1,200 ft from the runway threshold, the calculated airspeed was 58 knots, and when 600 ft from the threshold the airspeed was 54 knots. The final recorded data point coincided with the wreckage location and the recorded airspeed was 33 knots. Figure 3 depicts the plotted airspeed during the final portion of the accident flight. The chief pilot for the operator witnessed the accident. He stated that he heard the pilot announce that he was at “Sand Bay”, a location that the operator’s pilots use as a reporting point about 5 minutes from the airport. He stated that he left his house, which is adjacent tothe airport, to meet the airplane and he could see the airplane was flying very slowly, in a near stall position. He stated that it appeared to be flying nose-up with no power. He realized that the pilot only had a few seconds to lower the nose and add power before the airplane stalled. His first reaction was that the airplane was “wallowing” and no one was flying the airplane. He stated that the airplane did not recover from the nose-high attitude, then stalled and impacted the ground about 100 ft from the runway. Figure 3. Airspeed during the final portion of the flight. According to the operator’s report, the pilot had accumulated 2,949 hours of total flight experience with 136 hours in the accident airplane make and model. The pilot was hired by the operator on March 20, 2021, and the operator's training records indicated that the pilot completed the company indoctrination, aircraft ground training, emergency training, crew resource management training, special subjects training, flight training, and differences training between March 21 and July 13, 2021. He passed the airman competency/proficiency check in accordance with 14 CFR Parts 135.293, 135.297, and 135.299 on July 21, 2021. The pilot's flight duty summary indicated that his last duty day before the day of the accident was on November 1, 2021, 12 days before the accident. On that day the pilot was on duty for about 9.3 hours, logged 5.5 hours of flight time, and completed 17 landings. The airplane impacted the ground about 110 ft east of the extended centerline of runway 35, and 320 ft south of the runway threshold. The turf runway was 3,500 ft long and had a displaced threshold just beyond its intersection with paved runway 9/27. Impact signatures indicated that the airplane struck the ground in a left-wing-low, nose-low attitude. The front of the fuselage was crushed upward and aft. Figure 4. Overall view of the airplane wreckage at the accident site. All major components of the airplane were located at the accident scene. Flight control continuity was established from the cockpit controls to each respective control surface except for cuts made by first responders for occupant extraction. Engine control continuity was established from the cockpit to each engine except for cuts made by first responders for occupant extraction. The wing flaps were found in an extended position. Examination of the airframe, engines, and propellers did not reveal any preimpact mechanical malfunction or failures that would have precluded normal operation. ## Aircraft - Registration: [N866JA](https://openairdocs.org/aircraft/N866JA), registered now, S/N 185, built 1970 (OpenAirDocs) - Reported make and model: BRITTEN-NORMAN BN-2A - Registry model: [Britten-Norman BN-2A](https://openairdocs.org/model/britten-norman-bn-2a) (registry code 1520204) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 185 - Year built: 1970 - Airframe hours: 20784 - Engines: Lycoming O-540-E4C5 260 horsepower reciprocating; Lycoming O-540-E4C5 260 horsepower reciprocating - Damage: Substantial damage - Flight: Business, Part 135 - Operator: Mcphillips Flying Service Inc, doing business as Island Airways - Registered owner: Mcphillips Flying Service Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 28, 2021 - Departed: CVX, Charlevoix, MI - Destination: 6Y8, Beaver Island, MI - Flight plan: Company VFR - Airport: 6Y8, Welke, runway 17/35, 3,500 × 140 ft, grass/turf - Equipment: Stall warning system, ADS-B, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review July 21, 2021; seat: left; restraint: lap only; toxicology performed; flight hours: 2,949 total, 136 in this make and model, 2,606 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 320° at 11 knots, gusting 20 - Visibility: 10 statute miles - Temperature: 39 °F, dew point 32 °F - Altimeter: 29.73 inHg - Observed at: KSJX, 3 nm away - METAR: KSJX 131855Z AUTO 32011G20KT 10SM SCT020 SCT030 SCT038 04/00 A2973 RMK AO2 T00410001 ## 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 20211113017919A](https://openairdocs.org/incident/20211113017919A), Nov 13, 2021: Britten-Norman BN-2A, Beaver Island, MI, Substantial damage, 4 fatal. On November 13, 2021, at 1349 eastern standard time, a Britten Norman BN-2A airplane, N866JA, was substantially damaged when it was involved in an accident on… ## Docket (17 files) The files NTSB released with the investigation on October 5, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104239. 74.4 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15983481&FileExtension=pdf&FileName=NTSB%20report%206120-1_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 2, PDF, 3 pages, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15983657&FileExtension=pdf&FileName=Party%20member%20statements_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 3, PDF, 1 page, 913 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15983395&FileExtension=pdf&FileName=Wreckage%20Release_Redacted-Rel.pdf - Pilot training records (item 4, PDF, 22 pages, 8.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15983491&FileExtension=pdf&FileName=pilot%20record_Redacted-Rel.pdf - Pilot duty records (item 5, PDF, 2 pages, 227 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15985282&FileExtension=pdf&FileName=08172300-Rel.pdf - Aircraft examination notes (item 6, PDF, 5 pages, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15983187&FileExtension=pdf&FileName=Aircraft%20Examination%20Notes-Rel.pdf - Weight and balance information (item 7, PDF, 15 pages, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15982777&FileExtension=pdf&FileName=Weight%20and%20Balance%20Info_Redacted-Rel.pdf - Maintenance record excerpts (item 8, PDF, 40 pages, 44.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15983197&FileExtension=pdf&FileName=Maintenance%20Records_Redacted-Rel.pdf - GPS data from garmin handheld (item 9, CSV, 8 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15984248&FileExtension=csv&FileName=Accident-flight-Rel.csv - GPS kml file (item 10, KML, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15984790&FileExtension=kml&FileName=N866JA%20GPS-Rel.kml - ADS-B data csv file (item 11, CSV, 466 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15984800&FileExtension=csv&FileName=12900_20211113183000_Once-Rel.csv - ADS-B data kml file (item 12, KML, 602 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15983817&FileExtension=kml&FileName=ADSB%20data-Rel.kml - Autopsy memorandum (item 13, PDF, 1 page, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15985254&FileExtension=pdf&FileName=Autopsy%20Memo%20for%20Record-Rel.pdf - Toxicological report (item 14, PDF, 1 page, 472 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15983987&FileExtension=pdf&FileName=2021_199_001_Redacted-Rel.pdf - Excerpt from flight manual (item 15, PDF, 3 pages, 881 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15985024&FileExtension=pdf&FileName=1-Rel.pdf - Interview of pilot that landed before the accident airplane. (item 16, PDF, 1 page, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15985114&FileExtension=pdf&FileName=Interview%20of%20Pilot%20Who%20Landed%20Prior%20to%20Accident%20Airplane-Rel.pdf - Photos (item 17, PDF, 10 pages, 8.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16000147&FileExtension=pdf&FileName=Photo%20array-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.