GAA16CA411

NTSB accident investigation · Beech F33 · Blythe, CA · August 1, 2016

Accident · No injuriesData collectionFinal report
Date
August 1, 2016, 00:45 local (07:45 UTC)
Place
Blythe, CA
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N6728XBeech F33
Defining event
Initial climb: Loss of control in flight
Weather
Visual (VMC) · Night
Status
Completed · report January 18, 2017
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA
FAA report
20160801014669A
Case key
93750

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 failure to attain adequate airspeed to climb and her exceedance of the airplane's critical angle-of-attack during takeoff initial climb at night, which resulted in an aerodynamic stall at low altitude.

Findings · 3

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.

Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Capability exceededBeech F33A: 1 caseAll aircraft: 990 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotBeech F33A: 9 casesAll aircraft: 9,295 casesProbable cause
Light condition: darkEnvironmental issues › Conditions/weather/phenomena · Effect on personnelBeech F33A: 1 caseAll aircraft: 448 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 was conducting a night, visual meteorological conditions flight from a rural desert airport, and reported that prior to the flight, she did a weight and balance, checked the temperature, and did performance calculations. The pilot reported that after rotation, the airplane was not producing "sufficient power and not climbing as anticipated" and the stall warning horn was audible. She lowered the airplane's nose, and the stall warning horn silenced. The pilot further reported that she heard "scraping" [ground impact] against the airplane, but she could not see the terrain due to the night conditions. Subsequently, the airplane impacted the ground off of the airport, which resulted in substantial damage to the fuselage. In a follow up email conversation with the pilot's attorney, the attorney said that the pilot reported that the engine was producing power at the time that the aerodynamic stall warning horn was audible and just before impact, but noted that the power was not sufficient. A photograph of the accident airplane provided by the FAA inspector that responded to the accident, showed all three blades exhibited tip curl, torsional twisting and S-bending, consistent with the engine producing power at the time of impact. The airplane performance and weight and balance calculations that the pilot performed prior to the accident flight were requested by the National Transportation Safety Board investigator-in-charge (IIC), but were not provided. The pilot stated she was unaware of any preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. It is likely that the pilot exceeded the critical angle of attack during takeoff at night resulting in an aerodynamic stall. The Federal Aviation Administration has published the Airplane Flying Handbook FAA-H-8083-3A (2004). This handbook discusses aerodynamic stalls and states in part: The key to stall awareness is the pilot's ability to visualize the wing's angle of attack in any particular circumstance, and thereby be able to estimate his/her margin of safety above stall. This is a learned skill that must be acquired early in flight training and carried through the pilot's entire flying career. The pilot must understand and appreciate factors such as airspeed, pitch attitude, load factor, relative wind, power setting, and aircraft configuration in order to develop a reasonably accurate mental picture of the wing's angle of attack at any particular time. It is essential to flight safety that a pilot takes into consideration this visualization of the wing's angle of attack prior to entering any flight maneuver. Stall accidents usually result from an inadvertent stall at a low altitude in which a recovery was not accomplished prior to contact with the surface.

Factual narrative

"***This report was modified on December 22, 2016. Please see the docket for this accident to view the original report.*** The pilot was conducting a night, visual meteorological conditions flight from a rural desert airport, and reported that prior to the flight, she did a weight and balance, checked the temperature, and did performance calculations. The pilot reported that after rotation, the airplane was not producing "sufficient power and not climbing as anticipated" and the stall warning horn was audible. She lowered the airplane's nose, and the stall warning horn silenced. The pilot further reported that she heard "scraping" [ground impact] against the airplane, but she could not see the terrain due to the night conditions. Subsequently, the airplane impacted the ground off of the airport, which resulted in substantial damage to the fuselage. In a follow up email conversation with the pilot's attorney, the attorney said that the pilot reported that the engine was producing power at the time that the aerodynamic stall warning horn was audible and just before impact, but noted that the power was not sufficient. A photograph of the accident airplane provided by the FAA inspector that responded to the accident, showed all three blades exhibited tip curl, torsional twisting and S-bending, consistent with the engine producing power at the time of impact. The airplane performance and weight and balance calculations that the pilot performed prior to the accident flight were requested by the National Transportation Safety Board investigator-in-charge (IIC), but were not provided. The pilot stated she was unaware of any preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The Federal Aviation Administration has published the Airplane Flying Handbook FAA-H-8083-3A (2004). This handbook discusses aerodynamic stalls and states in part: The key to stall awareness is the pilot's ability to visualize the wing's angle of attack in any particular circumstance, and thereby be able to estimate his/her margin of safety above stall. This is a learned skill that must be acquired early in flight training and carried through the pilot's entire flying career. The pilot must understand and appreciate factors such as airspeed, pitch attitude, load factor, relative wind, power setting, and aircraft configuration in order to develop a reasonably accurate mental picture of the wing's angle of attack at any particular time. It is essential to flight safety that a pilot takes into consideration this visualization of the wing's angle of attack prior to entering any flight maneuver. Stall accidents usually result from an inadvertent stall at a low altitude in which a recovery was not accomplished prior to contact with the surface.

Aircraft

Registration
N6728X
Reported as
Beech F33 (A)
Category
Airplane
Serial number
CE-1023
Built
1983
Airframe hours
1,951.39
Engine
Continental IO-520BB, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 12, 2015
Departed
BLH · Blythe, CA
Destination
HND · Las Vegas, NV
Airport
BLH · Blythe, runway 17, 5,800 × 100 ft, asphalt
Equipment
Stall warning system, Auto-pilot

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
60
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
December 9, 2015
Seat
Left
Restraint
3-point
Flight hours
2,329.5 total · 513 in this make and model · 2,132.6 as pilot in command · 105.6 in the last 90 days · 33.2 in the last 30 days · 1.3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
200° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 72 °F
Altimeter
29.80 inHg
Observed at
KBLH, 1 nm away

Docket · 4

The files NTSB released with the investigation on November 8, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.6 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.

Other investigations on N6728X · 1

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