ERA21FA194

NTSB accident investigation · Beech C23 · Middleburg, FL · April 28, 2021

Accident · FatalClass 3 · FieldFinal report
Date
April 28, 2021, 09:00 local (13:00 UTC)
Place
Middleburg, FL
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
N6009UBeech C23
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA, Textron Aviation, Lycoming
FAA report
20210428007559A
Case key
102989

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 decision to depart from a soft grass runway with a tailwind, which resulted in an increased takeoff distance and subsequent impact with trees during the initial climb.

Findings · 4

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.

Wind: tailwindEnvironmental issues › Conditions/weather/phenomena · Decision related to conditionBeech C23: 4 casesAll aircraft: 594 casesProbable cause
Runway/land/takeoff/taxi surface: soft surfaceEnvironmental issues › Physical environment · Effect on equipmentBeech C23: 1 caseAll aircraft: 264 casesProbable cause
Aircraft capability: takeoff distanceAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech C23: 2 casesAll aircraft: 67 casesProbable cause

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 and two passengers were departing from a grass runway. The grass was several inches high and the ground was soft. There were no eyewitnesses to the accident; however, examination of wheel impressions left in the soft soil of the runway revealed that the airplane became airborne about 2,300 ft down the 3,700-ft-long runway and impacted 70- to 80-ft-tall trees about 800 ft past the runway end. Examination of the wreckage revealed no evidence of mechanical malfunctions with the airframe or engine that would have precluded normal operation. A witness who arrived at the accident site about 30 minutes after the accident, and a nearby weather observation around the time of the accident, indicated that the pilot likely departed with a tailwind. Review of the airplane’s takeoff performance chart indicated that, on a grass runway, the airplane’s predicted ground roll would be about 1,285 ft and about 2,151 ft was required to clear a 50-ft obstacle; however, the chart was based on the runway being dry, the grass short, and no wind. Based on the available information, it is likely that the pilot failed to account for the decreased takeoff performance due to the runway condition and the tailwind, which both would have increased required takeoff distance. Toxicology testing of specimens from the pilot detected the non-impairing local anesthetic medication lidocaine and the high blood pressure medication valsartan in blood and urine. It is unlikely that the pilot’s medical conditions or medications were factors in the accident. Toxicology testing of specimens from the pilot-rated passenger revealed the anti-anxiety medication alprazolam at 8 ng/mL in heart blood and in liver tissue. The antidepressant sertraline and its metabolite desmethylsertraline were detected in heart blood and liver tissue. The over-the-counter motion sickness medication meclizine was detected in liver. While it is unknown how well these conditions were controlled or if the pilot-rated passenger experienced any impairing side effects, the effects from the use of these medications would not have influenced the outcome of the takeoff, and it is unlikely that his anxiety or depression or the effects from his use of medication contributed to the accident.

Factual narrative

Per the Beechcraft C23 Sundowner Pilot’s Operating Handbook (POH), the aircraft takeoff speeds for safe operation are 65 knots at “lift-off,” and 74 knots at “50 ft.” The “Take-off Distance – Grass Surface” performance chart was interpolated for the associated conditions of 19°C and field elevation of 150 ft msl. The estimated ground roll with no wind was 1,285 ft and the distance to clear a 50-ft obstacle was 2,151 ft. The takeoff distance performance chart did not include information for calculating the adverse impact of tailwind conditions or a soft runway surface. The FAA Pilot’s Handbook of Aeronautical Knowledge (FAA-H-8083-25B), states: The effect of wind on takeoff distance is large, and proper consideration must also be provided when predicting takeoff distance… A tailwind that is 10% of takeoff airspeed increases the takeoff distance approximately 21 percent. The airport was located at an elevation of 150 ft mean sea level (msl), and its single turf runway was 3,800 ft long by 75 ft wide and oriented in a 9/27 configuration. Runway 27 sloped downward with an elevation change between the runway ends of about 40 ft. Trees that were an estimated 70 to 80 ft tall were present beyond the departure end of runway 27. On April 28, 2021, about 0900 eastern daylight time, a Beech C-23, N6009U, was destroyed when it was involved in an accident near Middleburg, Florida. The pilot, pilot-rated passenger, and second passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A witness described that, around 0840, he heard what he thought was the accident airplane departing from Spencer’s Airpark (FL13), Middleburg, Florida. Shortly thereafter, he heard the sirens of first responders as they proceeded toward the accident site. Toxicology testing was performed by the Federal Aviation Administration Forensic Sciences Laboratory on the pilot and pilot-rated passenger. Testing of specimens from the pilot detected the non-impairing local anesthetic medication lidocaine and the high blood pressure medication valsartan in blood and urine; carboxyhemoglobin was reported as not detected in iliac blood. The Office of the Medical Examiner detected carboxyhemoglobin at 15% in iliac blood; testing was negative for ethanol and drugs. Specimens from the pilot-rated passenger revealed the anti-anxiety medication alprazolam at 8 ng/mL in heart blood and liver tissue. The antidepressant sertraline and its metabolite desmethylsertraline were detected in the heart blood at 260 ng/mL and 582 ng/mL, respectively; both were also detected in lever tissue. The over-the-counter motion sickness medication meclizine was detected in liver. The 0915 recorded weather observation at Herlong Airport (HEG), Jacksonville, Florida, located about 16 miles northeast of the accident location, included wind from 140° at 7 knots, visibility 5 miles, clear of clouds, and temperature 23°C, dew point 18°C, and an altimetersetting of 30.16 inches of mercury. A witness who arrived at the airport about 30 minutes after the accident stated that, at that time, the wind was coming from the east (tailwind for runway 27) at an estimated velocity of 15 knots. A witness who arrived at the airport about 30 minutes after the accident stated that, at that time, the wind was coming from the east (tailwind for runway 27) at an estimated velocity of 15 knots. The accident site was located in a heavily wooded area about 800 ft beyond the departure end of runway 27. Multiple tree branches that displayed angular cuts were found along a path that extended from the trees near the departure end of the runway to the wreckage. The fuselage came to rest upright oriented on a heading of 180° magnetic. The airplane was partially consumed by a postaccident fire. The engine remained attached to the firewall through the tubular engine mount and was heavily fire damaged. The propeller remained attached to the engine crankshaft flange. The spinner dome and one propeller blade were embedded in the soft earth. The engine oil sump, carburetor, and the lower portion of the accessory case were consumed in the post-impact fire. The engine-driven fuel pump, vacuum pump, and both magnetos were heavily fire damaged. The cabin and instrument panel were also consumed by the postimpact fire. The wings sustained tree impact damage and were partially separated from the fuselage. Both wings came to rest in front of the engine and sustained significant postimpact fire damage. The right flap was separated from the wing and remained in one piece. A small fragment of the left flap was found forward of the engine. The empennage sustained minimal impact damage; however, it was thermally damaged. Flight control cable continuity was established to the rudder and stabilator. Aileron and flap continuity were partially established due to multiple separations that displayed signatures consistent with overload separation and postimpact fire damage. The manual flap handle ratchet plate was loose; and the position of the flaps at the time of the accident could not be determined. The stabilator trim was found in a position that correlated to about 8° tab trailing edge down. Examination of the runway surface revealed that the turf had not been recently mowed and was several inches high. The soil was soft. There were 1.5-inch-deep wheel impression marks from the airplane leading from the pilot’s hangar to the takeoff point on the runway. The tire impressions measured about 2,300 ft from the approach end of runway 27 to the takeoff point. The distance from the takeoff point to the trees was about 1,300 ft.

Aircraft

Registration
N6009U
Reported as
Beech C23
Category
Airplane
Serial number
M-2088
Built
1978
Engine
Lycoming O&VO-360 SER, 180 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Airport
FL13 · Spencers Airpark, runway 27, 3,700 × 75 ft, grass/turf
Equipment
Unknown

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
77
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
BasicMed, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
435 total
Role
Pilot
Age
78
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
BasicMed, With waivers/limitations
Seat
Right
Toxicology
Performed
Flight hours
840 total

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 7 knots
Visibility
5 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 64 °F
Altimeter
30.16 inHg
Observed at
HEG, 16 nm away
METAR
KHEG 281315Z AUTO 14007KT 5SM HZ CLR 23/18 A3016 RMK AO2

Docket · 13

The files NTSB released with the investigation on February 24, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 35.2 MB 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 N6009U · 1

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