# NTSB GAA16CA320: Beech 77, N60189, Santa Fe, NM, June 16, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: June 15, 2016, 21:40 local (Jun 16, 2016, 03:40 UTC) - Place: Santa Fe, NM - Coordinates: 35.582221, -106.105834 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.5822&lon=-106.1058&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of lift](https://openairdocs.org/ntsb-events/500) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report August 31, 2016 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 93398 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA16CA320 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93398/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93398 - Page: https://openairdocs.org/ntsb/GAA16CA320 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Aircraft capability: maximum weight](https://openairdocs.org/ntsb-findings/01061035): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Beech 77, 1 case](https://openairdocs.org/ntsb-findings/01061035/cases.md?model=1153007), [All aircraft, 152 cases](https://openairdocs.org/ntsb-findings/01061035/cases.md) - [Aircraft capability: climb capability](https://openairdocs.org/ntsb-findings/01061010): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Beech 77, 2 cases](https://openairdocs.org/ntsb-findings/01061010/cases.md?model=1153007), [All aircraft, 183 cases](https://openairdocs.org/ntsb-findings/01061010/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech 77, 5 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1153007), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Alertness/Fatigue](https://openairdocs.org/ntsb-findings/02013500): Personnel issues › Physical · Pilot (probable cause); cases with it: [Beech 77, 1 case](https://openairdocs.org/ntsb-findings/02013500/cases.md?model=1153007), [All aircraft, 48 cases](https://openairdocs.org/ntsb-findings/02013500/cases.md) - [Temp/humidity/pressure: high density altitude](https://openairdocs.org/ntsb-findings/03031020): Environmental issues › Conditions/weather/phenomena · Decision related to condition; cases with it: [Beech 77, 1 case](https://openairdocs.org/ntsb-findings/03031020/cases.md?model=1153007), [All aircraft, 278 cases](https://openairdocs.org/ntsb-findings/03031020/cases.md) - [Object/animal/substance: sign/marker](https://openairdocs.org/ntsb-findings/03022015): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Beech 77, 2 cases](https://openairdocs.org/ntsb-findings/03022015/cases.md?model=1153007), [All aircraft, 214 cases](https://openairdocs.org/ntsb-findings/03022015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Beech 77, 1 case](https://openairdocs.org/ntsb-events/030/sequence.md?model=1153007), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Initial climb: Other weather encounter](https://openairdocs.org/ntsb-events/400); cases with it: [Beech 77, 2 cases](https://openairdocs.org/ntsb-events/400/sequence.md?model=1153007), [All aircraft, 1,127 cases](https://openairdocs.org/ntsb-events/400/sequence.md) - [Initial climb: Loss of lift](https://openairdocs.org/ntsb-events/500) (defining event); cases with it: [Beech 77, 1 case](https://openairdocs.org/ntsb-events/500/sequence.md?model=1153007), [All aircraft, 252 cases](https://openairdocs.org/ntsb-events/500/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech 77, 9 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1153007), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N60189-2018-06-26), registration cancelled 2018-06-26, S/N WA-7, built 1979 (OpenAirDocs) - Reported make and model: BEECH 77 (NO SERIES) - Registry model: [Beech 77](https://openairdocs.org/model/beech-77) (registry code 1153007) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: WA-7 - Year built: 1979 - Airframe hours: 2730 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 31; injuries: none; 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 ## 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 20160615010419A](https://openairdocs.org/incident/20160615010419A), Jun 15, 2016: Beech 77, Santa Fe, NM, Substantial damage. On June 15, 2016, at 21:22 MDT, N60189, a Beechcraft model BE77, S/N-WA-7 airplane registered to the pilot was on a cross country flight from Santa Fe, new… ## Docket (7 files) The files NTSB released with the investigation on August 18, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93398. 4.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 831 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443302&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Weight and Balance Pilot Statement (item 2, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443303&FileExtension=.PDF&FileName=Weight%20and%20Balance%20Pilot%20Statement-Master.PDF - Compression Test Pilot Statement (item 3, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443304&FileExtension=.PDF&FileName=Compression%20Test%20Pilot%20Statement-Master.PDF - NTSB Performance Calculation (item 4, .PDF, 205 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443305&FileExtension=.PDF&FileName=NTSB%20Performance%20Calculation-Master.PDF - Accident Photo (Courtesy of FAA) (item 5, .PDF, 1 photo, 958 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443306&FileExtension=.PDF&FileName=Accident%20Photo%20(Courtesy%20of%20FAA)-Master.PDF - FAA P8740-02 Density Altitude (item 6, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443307&FileExtension=.PDF&FileName=FAA%20P8740-02%20Density%20Altitude-Master.PDF - Pilots Handbook of Aeronautical Knowledge FAA Excerpts (item 7, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443308&FileExtension=.PDF&FileName=Pilots%20Handbook%20of%20Aeronautical%20Knowledge%20FAA%20Excerpts-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.