# NTSB GAA16CA191: Beech C23, N2397E, Frenchville, ME, March 30, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: March 30, 2016, 11:00 local (15:00 UTC) - Place: Frenchville, ME - Coordinates: 47.285556, -68.312774 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=47.2856&lon=-68.3128&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report June 1, 2016 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA Portland FSDO - NTSB case key (mKey): 93005 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA16CA191 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93005/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93005 - Page: https://openairdocs.org/ntsb/GAA16CA191 ## Probable cause The pilot's failure to maintain directional control during the takeoff roll on a runway contaminated with ice and snow, which resulted in a runway excursion and an impact with a snowbank. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech C23, 23 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1151242), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech C23, 10 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=1151242), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Runway/land/takeoff/taxi surface: snow/slush/ice covered surface](https://openairdocs.org/ntsb-findings/03023015): Environmental issues › Physical environment · Effect on operation (probable cause); cases with it: [Beech C23, 1 case](https://openairdocs.org/ntsb-findings/03023015/cases.md?model=1151242), [All aircraft, 219 cases](https://openairdocs.org/ntsb-findings/03023015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Other weather encounter](https://openairdocs.org/ntsb-events/400); cases with it: [Beech C23, 5 cases](https://openairdocs.org/ntsb-events/400/sequence.md?model=1151242), [All aircraft, 1,127 cases](https://openairdocs.org/ntsb-events/400/sequence.md) - [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Beech C23, 9 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=1151242), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Takeoff: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Beech C23, 6 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=1151242), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Beech C23, 9 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=1151242), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech C23, 25 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151242), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that he landed the airplane on the runway with visible ice and snow, and noted no issues with the braking and steering capabilities of the airplane. He reported that during the subsequent takeoff roll with full power applied, the airplane started sliding to the left. He attempted to control the sliding with right rudder. During the acceleration, he reported the left main landing gear got trapped in area with ice and the airplane departed the runway to the left and impacted a snowbank. The airplane sustained substantial damage to an engine mount and to the fuselage. The pilot verified that there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. The Federal Aviation Administration has published the Aeronautical Information Manual (2014). This manual provides the definition of a contaminated runway and states in part: A runway is considered contaminated whenever standing water, ice, snow, slush, frost in any form, heavy rubber, or other substances are present. ## Factual narrative The pilot reported that he landed the airplane on the runway with visible ice and snow, and noted no issues with the braking and steering capabilities of the airplane. He reported that during the subsequent takeoff roll with full power applied, the airplane started sliding to the left. He attempted to control the sliding with right rudder. During the acceleration, he reported the left main landing gear got trapped in area with ice and the airplane departed the runway to the left and impacted a snowbank. The airplane sustained substantial damage to an engine mount and to the fuselage. The pilot verified that there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. The Federal Aviation Administration has published the Aeronautical Information Manual (2014). This manual provides the definition of a contaminated runway and states in part: A runway is considered contaminated whenever standing water, ice, snow, slush, frost in any form, heavy rubber, or other substances are present. ## Aircraft - Registration: [N2397E](https://openairdocs.org/aircraft/N2397E), registered now, S/N M-1949, built 1977 (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-1949 - Year built: 1977 - Airframe hours: 2437.2 - Engines: Lycoming O-360-A4K 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Maine Instrument Flight - Registered owner: Maine Instrument Flight - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 20, 2015 - Departed: FVE, Frenchville, ME - Destination: SFM, SANFORD, ME - Airport: FVE, Northern Aroostook Rgnl, runway 14, 4,600 × 75 ft, asphalt - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: none; private; airplane ratings: single-engine land; medical: class 2, with waivers/limitations; seat: left; restraint: 3-point; flight hours: 125 total, 41 in this make and model, 58 as pilot in command, 25 in the last 90 days, 8 in the last 30 days, 1.7 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 11 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 30 °F, dew point 18 °F - Altimeter: 30.03 inHg - Observed at: KFVE ## 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 20160330002169A](https://openairdocs.org/incident/20160330002169A), Mar 30, 2016: Beech C23, Frenchville, ME, Substantial damage. Pilot in command of N2397E was in the take off roll departing runway 14 at Frenchville Aroostook rgnl airport (fve) located in Frenchville, Maine, after an… ## Docket (4 files) The files NTSB released with the investigation on May 25, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93005. 4.5 MB in all. - Pilot Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440375&FileExtension=.PDF&FileName=Pilot%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440376&FileExtension=.PDF&FileName=Operator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Accident Photographs (Courtesy of FAA) (item 3, .PDF, 3 photos, 657 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440377&FileExtension=.PDF&FileName=Accident%20Photographs%20(Courtesy%20of%20FAA)-Master.PDF - Pilot's Statement (item 4, .PDF, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440378&FileExtension=.PDF&FileName=Pilot%27s%20Statement-Master.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.