# NTSB CEN23LA419: Beech A36, N67CD, El Dorado, AR, September 23, 2023 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: September 23, 2023, 16:25 local (21:25 UTC) - Place: El Dorado, AR - Coordinates: 33.1662, -92.606 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.1662&lon=-92.6060&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Unknown or undetermined](https://openairdocs.org/ntsb-events/000) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Textron Aviation, Federal Aviation Administration, Little Rock FSDO - NTSB case key (mKey): 193124 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23LA419 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193124/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=193124 - Page: https://openairdocs.org/ntsb/CEN23LA419 ## Probable cause A loss of engine power for undetermined reasons, which resulted in a forced landing and impact with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Aircraft](https://openairdocs.org/ntsb-findings/01050000): Aircraft › Aircraft power plant · Unknown/Not determined (probable cause); cases with it: [Beech A36, 2 cases](https://openairdocs.org/ntsb-findings/01050000/cases.md?model=1151604), [All aircraft, 151 cases](https://openairdocs.org/ntsb-findings/01050000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Fuel related](https://openairdocs.org/ntsb-events/190); cases with it: [Beech A36, 2 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=1151604), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Enroute: Unknown or undetermined](https://openairdocs.org/ntsb-events/000) (defining event); cases with it: [Beech A36, 11 cases](https://openairdocs.org/ntsb-events/000/sequence.md?model=1151604), [All aircraft, 1,703 cases](https://openairdocs.org/ntsb-events/000/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech A36, 78 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151604), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis According to the pilots, the airplane operated normally during the first two hours of the cross-country instructional flight. The flight instructor reported he then noticed the fuel flow seemed a little high. When the flight instructor reduced the mixture setting, the engine began to run rough. The instructor increased the mixture, which smoothed the engine roughness. The engine ran rough again, and the instructor once again increased the mixture setting, which smoothed the engine roughness. The engine then ran rough two additional times; both times the instructor increased the mixture setting, causing the roughness to cease. The engine roughness occurred again but was worse than he previously experienced. The instructor increased the mixture control to its full forward position and decided to divert to an alternate airport. The engine lost power while en route to the alternate airport, and the flight instructor performed a hard gear-up forced landing in a field, resulting in substantial damage to the fuselage and wings. Postaccident examination of the airplane revealed an adequate amount of fuel was present and a postaccident engine test run revealed no mechanical anomalies that would have precluded normal engine operation. ## Factual narrative On September 23, 2023, at 1625 central daylight time, a Beech A36, N67CD, was involved in an accident near El Dorado, Arkansas. The airplane sustained substantial damage. The pilot and a flight instructor received minor injuries. The airplane was operated under Title 14 Code of Federal Regulations Part 91 as an instructional flight. The airplane engine was equipped with a turbocharger through a supplemental type certificate installation. About six weeks before the accident flight, the airplane exhibited a loss of engine power. The accident flight was a cross-country flight to provide the pilot/airplane owner with training required by the pilot’s insurance carrier. During the accident flight, the airplane operated normally during the first two hours of the flight but was then followed by a fuel flow/consumption rate of about 22 gph, which seemed a little high to the flight instructor. When the instructor tried to reduce the mixture setting, the engine began to run rough, which he thought was unusual. They advanced the mixture, and the engine smoothed out. The engine then began to run rough again, and the instructor increased the mixture setting, which smoothed the engine roughness. The engine began to run rough again, and the instructor increased the mixture setting again, which smoothed the engine roughness. The engine then ran rough two additional times; both times the instructor increased the mixture setting, causing the engine roughness to cease. The engine roughness occurred again but was worse than the roughness they previously experienced. The instructor increased the mixture control to its full forward position and decided to divert to an alternate airport. The engine lost power while en route to the alternate airport, and the flight instructor performed a forced landing to a field. During the landing, the airplane sustained substantial damage to the fuselage and wings. During the recovery of the airplane from the accident site, about 50 gallons of 100 low lead aviation fuel was drained from the aircraft. The left wing fuel tank contained about 20 gallons of fuel and the fuel within the right wing fuel tank had drained onto the ground due to an impact-related breach of the right wing fuel tank. The auxiliary fuel tanks had an unknown quantity of fuel. During a postaccident test run of the engine, power settings from idle to maximum power were used. The engine started without hesitation and ran smoothly and without the symptoms that occurred during the accident flight. No anomalies that would have precluded normal operation were present during the test run. Maintenance records indicate the engine was sent out for overhaul and was reinstalled on the airplane about one month before the accident. A maintenance entry dated 12 days before the accident indicated the fuel pump was adjusted to set the fuel flow to 35.9 gallons per hour at full power. ## Aircraft - Registration: [N67CD](https://openairdocs.org/aircraft/N67CD), registered now, S/N E-2554 (OpenAirDocs) - Reported make and model: BEECH A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-2554 - Year built: 1990 - Engines: Continental IO-550-B45B 300 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Registered owner: Aspen Aircraft LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 27, 2023 - Departed: JKA, Gulf Shores, AL - Destination: HSD, Oklahoma City, OK - Flight plan: IFR - Airport: F43, El Dorado Downtown Airport-Stevens Field - Equipment: Electronic multifunction display, Stall warning system, ADS-B, Auto-pilot, Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 67; injuries: minor; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review January 6, 2023; seat: right; restraint: 3-point; flight hours: 3,247 total, 99 in this make and model, 2,950 as pilot in command, 85 in the last 90 days, 40 in the last 30 days, 4 in the last 24 hours - Pilot; age 54; injuries: minor; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review September 29, 2021; seat: left; restraint: 3-point; flight hours: 292 total, 4 in this make and model, 214 as pilot in command, 16 in the last 90 days, 2 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 91 °F, dew point 72 °F - Altimeter: 29.86 inHg - Observed at: ELD, 8 nm away - METAR: KELD 232153Z AUTO 10SM CLR 33/22 A2986 RMK AO2 SLP106 T03330222 ## 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 20230923016089A](https://openairdocs.org/incident/20230923016089A), Sep 23, 2023: Beech A36, El Dorado, AR, Substantial damage. Aircraft departed from gulf shores, al (kjka) airport, enroute to sundance airport, ok (khsd). While enroute at approximately 10,000FT and 30 miles southeast… ## Other investigations on N67CD (1) 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. - [NTSB GAA18CA412](https://openairdocs.org/ntsb/GAA18CA412), Jun 29, 2018: Beech A36 (N67CD), Spencer, IA, substantial damage. Probable cause: The pilot’s failure to extend the landing gear before landing. Contributing to the accident were the pilot’s failure to use the Before Landing checklist due to being distracted while communicating… ## Docket (13 files) The files NTSB released with the investigation on April 23, 2025, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=193124. 31.9 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 - flight instructor (item 1, PDF, 7 pages, 6.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18170803&FileExtension=pdf&FileName=6120%20Flight%20Instructor%20Master_Redacted-Rel.pdf - Flight instructor's statement (item 2, PDF, 2 pages, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18293327&FileExtension=pdf&FileName=Flight%20Instructor%20Statement-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 - pilot (item 3, PDF, 8 pages, 800 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18293620&FileExtension=pdf&FileName=NTSB%20Pilot%20accident%20report%2010-9-23%20Pilot_Redacted-Rel.pdf - Memorandum for record a�� dawsons aircraft (item 4, PDF, 1 page, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18295881&FileExtension=pdf&FileName=MOR%20Template%20-%20Dawson-Rel.pdf - Maintenance records (item 5, PDF, 12 pages, 15.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18170989&FileExtension=pdf&FileName=67CD%20LBE_Redacted-Rel.pdf - Memorandum for record a�� engine run (item 6, PDF, 1 page, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18296775&FileExtension=pdf&FileName=MOR%20Template%20-%20Engine%20Run-Rel.pdf - Electronic devices - specialist's factual report (item 7, PDF, 15 pages, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18202841&FileExtension=pdf&FileName=CEN23LA419%20Electronic%20Devices%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - Attachment 1 to electronic devices - specialist's factual report (item 8, CSV, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18202562&FileExtension=csv&FileName=CEN23LA419%20Attachment%201%20to%20Electronic%20Devices%20-%20Specialist%27s%20Factual%20Report-Rel.csv - Attachment 2 to electronic devices - specialist's factual report (item 9, CSV, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18202880&FileExtension=csv&FileName=CEN23LA419%20Attachment%202%20to%20Electronic%20Devices%20-%20Specialist%27s%20Factual%20Report-Rel.csv - Statement of party representatives to NTSB investigation - Textron aviation (item 10, PDF, 1 page, 757 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18297230&FileExtension=pdf&FileName=Party%20Statement%20Textron_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 11, PDF, 2 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18306325&FileExtension=pdf&FileName=Party%20Master%20Redacted-Rel.pdf - Photos (item 12, PDF, 2 pages, 639 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18299147&FileExtension=pdf&FileName=Photo%20Template-Rel.pdf - Memorandum for record a�� NTSB factual report review by Continental aerospace technologies (item 13, PDF, 1 page, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18524418&FileExtension=pdf&FileName=MOR%20Template%20Continental%20Report%20Review-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.