# NTSB CHI93LA162: Beech A33-35, N397Z, Theodosia, MO, May 5, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: May 5, 1993, 15:35 local (20:35 UTC) - Place: Theodosia, MO - Coordinates: 36.569889, -92.659172 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.5699&lon=-92.6592&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 3 serious - Status: Completed, report June 30, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 9208 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI93LA162 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/9208/pdf - Page: https://openairdocs.org/ntsb/CHI93LA162 ## Probable cause POOR PREFLIGHT PLANNING/PREPARATION BY THE PILOT. FACTORS RELATED TO THE ACCIDENT WERE THE TAILWIND, A HEAVY WEIGHT LOAD, AND UNSUITABLE TERRAIN IN WHICH TO LAND THE AIRPLANE. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - weather condition - tailwind (contributing factor) - aircraft weight and balance (contributing factor) - preflight planning/preparation - poor, pilot in command (cause) - proper climb rate - not possible, pilot in command - Forced landing, descent - emergency - In flight collision with terrain/water, landing - flare/touchdown - terrain condition - none suitable (contributing factor) - object - tree(s) ## Analysis THE PILOT INITIATED THE TAKEOFF TO THE WEST ON A DOWNHILL RUNWAY WITH A TAILWIND OF APPROXIMATELY 9 KNOTS. UPON REACHING 200 FEET AGL, THE PILOT REPORTED A LOSS IN POWER AND WAS UNABLE TO MAINTAIN ALTITUDE. A FORCED LANDING WAS MADE INTO TREES. THE AIRPLANE SETTLED TO THE TERRAIN IN AN INVERTED POSITION AND A POST IMPACT FIRE ERUPTED. POST ACCIDENT INSPECTION FAILED TO REVEAL ANY FAILURE/MALFUCNTION OF THE AIRCRAFT OR ENGINE WHICH WOULD HAVE RESULTED IN A LOSS OF POWER. JUST PRIOR TO THE ACCIDENT, THE PILOT AVOIDED TAKING OFF FROM ANOTHER AIRPORT WITH THIS PASSENGER LOAD DUE TO WEIGHT CONCERNS. ## Factual narrative On May 5, 1993, at 1535 central daylight time, a Beech A33-35, N397Z, operated by Robert D. Borman collided with the trees shortly after takeoff. Visual meteorological conditions prevailed and no flight plan was filed. The airplane was destroyed. The pilot and two passengers were seriously injured. A third passenger received fatal injuries. The flight originated from the Lost Mine Airport, a private airport in Theodosia, Missouri, just prior to the accident. The pilot reported that prior to the accident he and his passengers had flown to Gainsville, Missouri, to attend a conference. He reported that due to the short runway (1,890') at Gainsville and the weight of all three passengers, he flew to the Lost Mine Airport with two passengers on board, dropped them off and returned to Gainsville to pick up the third passenger. Upon landing at Lost Mine with the third passenger, the pilot reported, he taxied to the end of the runway, picked up the other passengers and was departing when the accident occurred. The pilot reported that the airplane seemed to be performing okay until an altitude of 200' was reached on takeoff, at which time the engine began to "slow down, showing a drop in power and RPM's." He reported he lowered the nose in an attempt to maintain airspeed and looked for a place to land. The pilot ultimately stalled the airplane into trees. He reported the airplane contacted the trees at 50 mph and spun 180 degrees upside down prior to settling to the terrain in an inverted position. A post impact fire erupted. A witness at a nearby farm reported hearing the airplane and reported that the engine sounded like it was "lugging down" as if under a heavy load. A post accident inspection of the airplane and engine was conducted by a Federal Aviation Administration Principal Maintenance Inspector. His statement of the inspection is attached to this report. The pilot departed downhill on runway 27 at the Lost Mine Airport. Winds at the time of the departure were from the south-southeast at 9 knots. After the departure the pilot made a right hand turn to the north. ## Aircraft - Registration: [N397Z](https://openairdocs.org/deregistered/N397Z-1993-10-07), registration cancelled 1993-10-07, S/N CD275 (OpenAirDocs) - Reported make and model: BEECH A33-35 - Registry model: [Beech 35-A33](https://openairdocs.org/model/beech-35-a33) (registry code 1151404) (OpenAirDocs) - Category: Airplane - Serial number: CD-275 - Airframe hours: 3200 - Engines: CONTINENTAL IO-470-J 225 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Robert D. Borman - Registered owner: Robert D. Borman - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 26, 1992, 40 hours before - Destination: MARSHFIELD, MO - Airport: PVT, Lost Mine Airport, runway 27, 3,000 × 50 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 38; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 655 total, 149 in this make and model, 31 in the last 90 days, 3 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 135° at 9 knots - Visibility: 15 statute miles - Lowest ceiling: none - Temperature: 75 °F ## 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 19930505012319A](https://openairdocs.org/incident/19930505012319A), May 5, 1993: Beech 35A33, Theodosia, MO, Destroyed, 1 fatal. Full load and quartering tail wind on takeoff. Poor climb. Stalled into trees. Too much flap. No engine defects. 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.