GAA16CA320

NTSB accident investigation · Beech 77 · Santa Fe, NM · June 16, 2016

Accident · No injuriesData collectionFinal report
Date
June 15, 2016, 21:40 local (Jun 16, 2016, 03:40 UTC)
Place
Santa Fe, NM
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N60189Beech 77
Defining event
Initial climb: Loss of lift
Weather
Visual (VMC) · Night
Status
Completed · report August 31, 2016
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA
FAA report
20160615010419A
Case key
93398

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

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Probable cause

The pilot's decision to takeoff over the maximum takeoff weight in high density altitude conditions, which resulted in an inability to climb above terrain, a forced landing, and a collision with a road sign. Contributing to the accident was the pilot's decision to fly in a fatigued mental state.

Findings · 6

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.

Aircraft capability: maximum weightAircraft › Aircraft oper/perf/capability · Capability exceededBeech 77: 1 caseAll aircraft: 152 casesProbable cause
Aircraft capability: climb capabilityAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleBeech 77: 2 casesAll aircraft: 183 casesProbable cause
Alertness/FatiguePersonnel issues › Physical · PilotBeech 77: 1 caseAll aircraft: 48 casesProbable cause
Temp/humidity/pressure: high density altitudeEnvironmental issues › Conditions/weather/phenomena · Decision related to conditionBeech 77: 1 caseAll aircraft: 278 cases
Object/animal/substance: sign/markerEnvironmental issues › Physical environment · Contributed to outcomeBeech 77: 2 casesAll aircraft: 214 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 reported that during the initial climb in night visual meteorological conditions the airplane "was not climbing well." The pilot further reported for about 15 minutes he maneuvered the airplane over a highway, and the airplane still would not gain altitude. Subsequently, he reported that was "unable to maintain adequate terrain separation" and landed on the highway. During the landing roll on the highway, the pilot swerved to avoid a car and struck a road sign, which substantially damaged the left wing. During postaccident correspondence with the pilot, he reported that the airplane was "160 lbs. over gross with high estimates on bags, likely closer to 140 over gross." The Federal Aviation Administration (FAA) Pilot's Handbook of Aeronautical Knowledge (PHAK) in part states: "The pilot should always be aware of the consequences of overloading. An overloaded aircraft may not be able to leave the ground, or if it does become airborne, it may exhibit unexpected and unusually poor flight characteristics. If not properly loaded, the initial indication of poor performance usually takes place during takeoff." The pilot also reported that a cold compression check was performed on the engine after the accident. He reported that the "compressions were 25/80, 42/80, and both rear cylinders were 72/80." The Service Instructions for cylinder compression checks provided by Textron Lycoming in part states: "Operate the engine until normal cylinder head and oil temperatures are attained; then shut down the engine making sure that magneto switches and fuel supply valves are shut off. Proceed with the test as soon as possible after shut down." The cylinder compression measured was not completed in accordance with the manufacture's service instructions. The FAA provides guidance on how density altitude affects aircraft performance. The density altitude about the time of departure was 8,202 feet, the pressure altitude was 6,217 feet, and the temperature was 20 Celsius (68 Fahrenheit). According to the FAA Koch Chart, the airplane would have likely experienced a 145% increase to the "normal takeoff distance" and a 65% decrease in a normal climb rate. The FAA PHAK in part states: "In extreme conditions, such as high gross weight, high density altitude, and high temperature, a deficiency of airspeed during takeoff may permit the aircraft to become airborne but be incapable of sustaining flight out of ground effect." The pilot also reported that he had been on a four day trip and had worked more than 12 hours each day, including the day of the accident. He reported that, "fatigue significantly affected decision making as [the] pilot had opportunities to attempt to land back at [the] airport, abort [the] takeoff, or land closer on [the] highway avoiding the vehicle." The FAA PHAK in part states: "Fatigue is frequently associated with pilot error. Some of the effects of fatigue include degradation of attention and concentration, impaired coordination, anddecreased ability to communicate. These factors seriously influence the ability to make effective decisions."

Factual narrative

The pilot reported that during the initial climb in night visual meteorological conditions the airplane "was not climbing well." The pilot further reported for about 15 minutes he maneuvered the airplane over a highway, and the airplane still would not gain altitude. Subsequently, he reported that was "unable to maintain adequate terrain separation" and landed on the highway. During the landing roll on the highway, the pilot swerved to avoid a car and struck a road sign, which substantially damaged the left wing. During postaccident correspondence with the pilot, he reported that the airplane was "160 lbs. over gross with high estimates on bags, likely closer to 140 over gross." The Federal Aviation Administration (FAA) Pilot's Handbook of Aeronautical Knowledge (PHAK) in part states: "The pilot should always be aware of the consequences of overloading. An overloaded aircraft may not be able to leave the ground, or if it does become airborne, it may exhibit unexpected and unusually poor flight characteristics. If not properly loaded, the initial indication of poor performance usually takes place during takeoff." The pilot also reported that a cold compression check was performed on the engine after the accident. He reported that the "compressions were 25/80, 42/80, and both rear cylinders were 72/80." The Service Instructions for cylinder compression checks provided by Textron Lycoming in part states: "Operate the engine until normal cylinder head and oil temperatures are attained; then shut down the engine making sure that magneto switches and fuel supply valves are shut off. Proceed with the test as soon as possible after shut down." The cylinder compression measured was not completed in accordance with the manufacture's service instructions. The FAA provides guidance on how density altitude affects aircraft performance. The density altitude about the time of departure was 8,202 feet, the pressure altitude was 6,217 feet, and the temperature was 20 Celsius (68 Fahrenheit). According to the FAA Koch Chart, the airplane would have likely experienced a 145% increase to the "normal takeoff distance" and a 65% decrease in a normal climb rate. The FAA PHAK in part states: "In extreme conditions, such as high gross weight, high density altitude, and high temperature, a deficiency of airspeed during takeoff may permit the aircraft to become airborne but be incapable of sustaining flight out of ground effect." The pilot also reported that he had been on a four day trip and had worked more than 12 hours each day, including the day of the accident. He reported that, "fatigue significantly affected decision making as [the] pilot had opportunities to attempt to land back at [the] airport, abort [the] takeoff, or land closer on [the] highway avoiding the vehicle." The FAA PHAK in part states: "Fatigue is frequently associated with pilot error. Some of the effects of fatigue include degradation of attention and concentration, impaired coordination, anddecreased ability to communicate. These factors seriously influence the ability to make effective decisions."

Aircraft

Registration
N60189
Reported as
Beech 77 (NO SERIES)
Category
Airplane
Serial number
WA-7
Built
1979
Airframe hours
2,730
Engine
Lycoming O-235-L2C, 115 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · November 12, 2015
Departed
SAF · Santa Fe, NM
Destination
U77 · Spanish Fork, UT
Flight plan
VFR
Airport
SAF · Santa Fe Muni, runway 20, 8,366 × 150 ft, asphalt
Equipment
Handheld GPS

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
31
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
April 19, 2016
Seat
Left
Restraint
3-point
Flight hours
5,700 total · 8 in this make and model · 5,300 as pilot in command · 100 in the last 90 days · 30 in the last 30 days · 8 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
90° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
68 °F, dew point 14 °F
Altimeter
30.06 inHg
Observed at
KSAF, 4 nm away

Docket · 7

The files NTSB released with the investigation on August 18, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.6 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.