ERA10LA014

NTSB accident investigation · Beech E35 · Mount Morris, NY · October 10, 2009

Accident · Serious injuriesLimited investigationFinal report
Date
October 10, 2009, 15:45 local (19:45 UTC)
Place
Mount Morris, NY
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N3515BBeech E35
Defining event
Takeoff-rejected takeoff: Collision during takeoff/land
Weather
Visual (VMC) · Day
Status
Completed · report April 19, 2010
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20091010050789A
Case key
74885

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot’s improper decision to take off from unsuitable terrain with a quartering tailwind.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Runway/land/takeoff/taxi surfaceEnvironmental issues › Physical environment · Effect on operationBeech E35: 1 caseAll aircraft: 253 cases
Runway/land/takeoff/taxi surfaceEnvironmental issues › Physical environment · Decision related to conditionBeech E35: 1 caseAll aircraft: 253 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot attempted a quartering tailwind takeoff from a 1,200-foot turf runway to troubleshoot why the entry door would pop open on takeoff. Although the airplane initially became airborne, it was either unable to maintain flight, or the pilot elected to land it in a hayfield beyond the end of the runway. After inspecting the airplane, the pilot taxied it to another spot on the rough-surfaced hayfield, and attempted another quartering tailwind takeoff. Again, after briefly becoming airborne, the airplane landed, but then went through a hedgerow and crossed a drainage ditch. Other than the entry door, the pilot reported no mechanical anomalies with the airplane. The pilot did not have a logbook, and had not had a biennial flight review “in a few years,” but continued to fly on a regular basis. The pilot also did not hold a current medical certificate, and was taking prescribed medications on a daily basis that typically would not have been approved by the Federal Aviation Administration.

Factual narrative

On October 10, 2009, about 1545 eastern daylight time, a Beech E35, N3515B, was substantially damaged during a takeoff attempt from a hayfield in Mount Morris, New York. The certificated private pilot was seriously injured. Visual meteorological conditions prevailed, and no flight plan had been filed for the local personal flight, which was conducted under the provisions of 14 Code of Federal Regulations Part 91. According to initial reports from the pilot, the airplane had a history of the entry door popping open during takeoff and he was trying to troubleshoot the problem. The pilot attempted to take off from runway 4 at J.C. Palermo Airpark, Mount Morris, New York, a 1,200-foot runway at an elevation of 962 feet. However, when the door popped open, he became startled and aborted the takeoff, but too late to stay on the runway. The pilot also acknowledged that he attempted to take off downwind. In a later telephone interview, the pilot confirmed that he attempted the downwind takeoff, and while doing so, the airplane’s door opened. He also stated that the airplane never left the ground, and he therefore was conducting a high speed taxi. However, as noted in a state police report, three witnesses reported that the airplane did take off, with one stating that it reached an altitude of about 25 feet above the runway, before it landed in a hayfield beyond the end of the runway. The pilot never mentioned a second takeoff attempt. Two of the three witnesses stated that after landing in the hayfield beyond the runway, the pilot got out, inspected the airplane, and stated, “I think everything’s okay.” He later taxied the airplane across the hayfield and made a second takeoff attempt from there rather than the runway. Both witnesses indicated that the airplane briefly became airborne again before settling back down onto the field. The state police report noted ground scars about 600 feet in length which led through a hedgerow and across the drainage ditch to the airplane, which sustained fuselage and left wing damage. According to a Federal Aviation Administration (FAA) inspector, the ground scars headed northeast toward the airplane. In addition, the hayfield had a rough, uneven surface to it. The pilot stated that, other than the access door, there were no mechanical anomalies with the airplane. The pilot’s latest FAA medical certificate was “pending” as of May 23, 2000. According to a list provided to the FAA inspector, the pilot was utilizing prescribed medications on a daily basis, including alprazolam, carbamazepine, fluoxetine, and buspirone. The pilot also stated that he had lost his logbook and had not had a biennial flight review “in a few years,” but continued to fly on a regular basis. Weather, recorded at the airport in Dansville, New York, about 12 nautical miles (nm) to the southeast, at 1554, included winds from 280 degrees true at 8 knots. Weather, recorded at the airport in Rochester, New York, about 25 nm to the northeast, at 1554,included winds from 280 degrees true at 6 knots.

Aircraft

Registration
N3515B
Reported as
Beech E35
Category
Airplane
Serial number
D-3732
Airframe hours
3,915
Engine
Cont Motor E185 SERIES, 205 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 13, 2009
Departed
NONE · Mount Morris, NY
Destination
NONE · Mount Morris, NY
Airport
NONE · JC Palermo Airpark, runway 04, 1,200 × 50 ft, grass/turf

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
67
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Seat
Left
Flight hours
2,400 total · 1,800 in this make and model · 2,200 as pilot in command · 50 in the last 90 days · 25 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 8 knots
Visibility
10 statute miles
Temperature
57 °F, dew point 37 °F
Altimeter
30.05 inHg
Observed at
DSV, 12 nm away

Docket · 5

The files NTSB released with the investigation on February 12, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 752 KB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N3515B · 1

Matched to the same aircraft by N-number and date.