# NTSB ERA21FA148: Beech C23, N67013, Purcellville, VA, March 4, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: March 4, 2021, 15:10 local (20:10 UTC) - Place: Purcellville, VA - Coordinates: 39.23045, -77.74829 - Nearby events: https://openairdocs.org/map.md?lat=39.2304&lon=-77.7483&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Lycoming Engines, Textron Aviation - NTSB case key (mKey): 102711 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21FA148 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102711/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102711 - Page: https://openairdocs.org/ntsb/ERA21FA148 ## Probable cause The pilot's improper decision to depart from the short turf runway with a tailwind. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech C23, 8 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1151242), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Aircraft capability: takeoff distance](https://openairdocs.org/ntsb-findings/01061025): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible; cases with it: [Beech C23, 2 cases](https://openairdocs.org/ntsb-findings/01061025/cases.md?model=1151242), [All aircraft, 67 cases](https://openairdocs.org/ntsb-findings/01061025/cases.md) - [Wind: tailwind](https://openairdocs.org/ntsb-findings/03034015): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Beech C23, 4 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md?model=1151242), [All aircraft, 594 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Beech C23, 3 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=1151242), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis The pilot was attempting to depart from a 1,900-ft-long turf runway, and customarily would depart toward the south as the runway sloped downhill in that direction (a total elevation change of about 50 feet). A witness described that, during the takeoff, the airplane was departing with a tailwind. The wind conditions at the closest weather reporting station about 13 nautical miles away indicated that a right quartering tailwind likely prevailed, with a right crosswind component of 21 knots and a tailwind component of 12 knots, gusting to 14 knots. The airplane subsequently impacted the tops of trees about 300 feet beyond and to the left of the runway departure end, and continued about 300 feet farther before coming to rest. Postaccident examination of the wreckage revealed no evidence of any preaccident mechanical malfunctions or failures with the airplane or engine that would have precluded normal operation. The takeoff performance chart for the airplane indicated that a ground roll of 1,236 ft was required on a grass surface, and 2,068 ft was needed to clear a 50-ft obstacle. The chart did not contain a correction factor for a takeoff with a tailwind, which would require a longer ground roll and takeoff distance. With the available runway distance of 1,900 ft, the pilot would have been operating the airplane near the limits of its performance capability before accounting for the additional distance required due to the prevailing tailwind. Given this information, it is likely that the pilot’s decision to depart in the gusting tailwind conditions resulted in an inflight collision with trees during the initial climb. ## Factual narrative The “Take-off Distance – Grass Surface” performance chart in the airplane’s pilot operating handbook was interpolated for the associated conditions of 11°C and 750 ft elevation. The estimated ground roll with a 0 knot wind component was 1,236 ft, and the distance to clear a 50 ft obstacle was 2,068 ft. The takeoff distance performance chart did not include a tailwind component multiplier penalty. 14VA was located 2 miles northwest of Hillsboro, Virginia. It had one turf runway designated as 01/19, which was 1,900 ft long by 50 ft wide. The elevation at the approach end of runway 19 was 749 ft. The highest point on the runway was 756 ft, 400 ft from the runway 19 threshold. The elevation at the departure end of runway 19 was 690 ft. The airport was equipped with two windsocks: one about 500 ft from the departure end of runway 19 and one past the departure end of runway 19. On March 4, 2021, about 1510 eastern standard time, a Beech C-23, N67013, was substantially damaged when it was involved in an accident near Purcellville, Virginia. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot was departing from runway 19 at Krens Farm Airport (14VA), Hillsboro, Virginia. A witness reported hearing the airplane take off and looked back to watch it depart. When she saw the airplane, it was “tilted to the left” as it descended into the trees. She heard the engine the entire time and stated that it made “traditional engine noises.” In addition, she noted that relative to the airplane’s takeoff direction, a tailwind prevailed at the time of the accident. The pilot’s son reported that his father always took off from runway 19 because of the slope of the runway. The 1455 recorded weather observation at Leesburg Executive Airport (JYO), Leesburg, Virginia, located about 13 miles southeast of the accident location, included wind from 310° at 24 knots gusting to 29 knots. Interpolation of the crosswind component chart revealed that there was about a 21-knot right crosswind and a tailwind component of 12 knots gusting to 14 knots at the time of the accident. The airplane struck several trees beginning about 326 feet southeast of the departure end of runway 19 at an elevation of about 690 ft mean sea level. (see Figure 1.) From the area of the initial tree strikes, there was a debris field that was 306 ft long, oriented along a 128° magnetic heading. The main wreckage, comprised of the fuselage and right wing, came to rest in a heavily wooded area at the end of the debris field. There was no post impact fire and an odor of 100LL aviation fuel was noted at the site. All major components of the airplane were located in the vicinity of the main wreckage. Figure 1 - Accident site diagram depicting runway (dashed white lines), the initial tree impact scars, the debris path, and the main wreckage of the airplane. Also annotated is the reported wind direction and velocity at JYO. The leftwing was impact-separated at the wing root and located about 40 ft prior to the main wreckage. The outboard approximate 5 ft leading edge of the left wing was impact-damaged and crushed aft. The rudder was impact separated from the vertical stabilizer and the vertical stabilizer was impact-separated from the empennage and located about 20 ft prior to the main wreckage. The leading edge of the vertical stabilizer exhibited impact damage. The horizontal stabilator remained attached to the empennage. The right wing was impact-separated and remained attached to the fuselage through cables. Flight control continuity was established to all flight control surfaces from the flight controls in the cockpit. The engine was removed from the airframe for further examination. Crankshaft and valvetrain continuity were confirmed by rotating the propeller hub by hand. Thumb compression and suction were observed on all cylinders. The spark plugs were removed and examined. The Nos. 2 and 4 spark plugs were oil soaked. All other spark plugs were light gray in color and in new condition. Spark was observed on all towers of the left and right magneto when the input shaft was rotated. There were no anomalies noted with the engine that would have precluded normal operation prior to the accident. The fixed-pitch propeller remained attached to the engine. Both propeller blades remained attached to the propeller hub. One blade was bent aft about 45° and exhibited leading edge gouging and chordwise scratching. The other propeller blade was bent slightly aft and exhibited chordwise scratching, leading edge gouging, and tip tearing. ## Aircraft - Registration: [N67013](https://openairdocs.org/aircraft/N67013), registered now, S/N M-2229, built 1979 (OpenAirDocs) - Reported make and model: BEECH C23 (NO SERIES) - Registry model: [Beech C23](https://openairdocs.org/model/beech-c23) (registry code 1151242) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: M-2229 - Year built: 1979 - Airframe hours: 11968.9 - Engines: LYCOMING O-360-A4K 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal; Standard, Utility - Last inspection: Annual, October 12, 2020, 2.3 hours before - Destination: SHD, Weyers Cave, VA - Airport: 14VA, Krens Farm, runway 19, 1,900 × 50 ft, grass/turf - Equipment: Electronic flight bag or handheld device, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 77; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; restraint: 3-point; toxicology performed; flight hours: 4,000 total ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 24 knots, gusting 29 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 52 °F, dew point 27 °F - Altimeter: 29.90 inHg - Observed at: JYO, 13 nm away - METAR: KJYO 041955Z AUTO 31024G29KT 10SM CLR 11/M03 A2990 RMK AO2 ## 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 20210304002409A](https://openairdocs.org/incident/20210304002409A), Mar 4, 2021: Beech C23, Hillsboro, VA, Substantial damage, 1 fatal. On March 4, 2021 at approximately 1510 local time, aircraft N67013, a Beech C23, took off from Krens Farm Airport (14VA), a private grass runway. The aircraft… ## Docket (13 files) The files NTSB released with the investigation on January 10, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102711. 52.8 MB in all. - Accident site diagram (item 1, PDF, 1 page, 371 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12475370&FileExtension=pdf&FileName=Site%20Diagram-Rel.pdf - Witness interview summaries (item 2, PDF, 4 pages, 434 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12450464&FileExtension=pdf&FileName=Witness%20Interview%20Summaries-Rel.pdf - Wreckage examination summary (item 3, PDF, 9 pages, 4.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12475412&FileExtension=pdf&FileName=ERA21FA148%20-%20Wreckage%20Examination%20Summary-Rel.pdf - Maintenance record excerpts (item 4, PDF, 10 pages, 8.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12450474&FileExtension=pdf&FileName=Mx%20Logs%20FA148%20Docket_Redacted-Rel.pdf - Toxicological report - pilot (item 5, PDF, 1 page, 167 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12452080&FileExtension=pdf&FileName=Pilot%20Tox%20Report_Redacted-Rel.pdf - Autopsy memorandum for record (item 6, PDF, 1 page, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12451731&FileExtension=pdf&FileName=Autopsy%20Memorandum%20Of%20Record%20Color%20FA148-Rel.pdf - Weather factual report (item 7, PDF, 21 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12459004&FileExtension=pdf&FileName=ERA21FA148_weatherfactualSuffernfinal-Rel.pdf - Weather attachment 1 (item 8, GIF, 19.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12459280&FileExtension=gif&FileName=attachment1_animationSAT_VIS_1901to2101utc-Rel.gif - Weather attachment 2 (item 9, PDF, 5 pages, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12459769&FileExtension=pdf&FileName=attachment2_GFAimagedata-Rel.pdf - Performance calculations (item 10, PDF, 3 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12505755&FileExtension=pdf&FileName=Memorandum%20Of%20Record%20Color%20Performance%20Calculations-Rel.pdf - Investigative photographs (item 11, PDF, 7 pages, 7 photos, 11.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12475920&FileExtension=pdf&FileName=Photo%20Array%20FA148-Rel.pdf - Statement of party representatives to NTSB investigation (item 12, PDF, 11 pages, 414 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12474197&FileExtension=pdf&FileName=Party%20Forms%20Signed%20FA148_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 13, PDF, 1 page, 268 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12753266&FileExtension=pdf&FileName=Retention-Release-of-Wreckage-Form%20FA148-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.