# NTSB GAA16CA411: Beech F33, N6728X, Blythe, CA, August 1, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: August 1, 2016, 00:45 local (07:45 UTC) - Place: Blythe, CA - Coordinates: 33.631942, -114.716941 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.6319&lon=-114.7169&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report January 18, 2017 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 93750 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA16CA411 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93750/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93750 - Page: https://openairdocs.org/ntsb/GAA16CA411 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Beech F33A, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=1151425), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech F33A, 9 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1151425), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on personnel; cases with it: [Beech F33A, 1 case](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=1151425), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Beech F33A, 4 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=1151425), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Beech F33A, 9 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1151425), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Initial climb: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech F33A, 21 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151425), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N6728X-2017-01-23), registration cancelled 2017-01-23, S/N CE-1023, built 1983 (OpenAirDocs) - Reported make and model: BEECH F33 (A) - Registry model: [Beech F33A](https://openairdocs.org/model/beech-f33a) (registry code 1151425) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: CE-1023 - Year built: 1983 - Airframe hours: 1951.39 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: none; 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 ## 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 20160801014669A](https://openairdocs.org/incident/20160801014669A), Aug 1, 2016: Beech F33A, Blythe, CA, Substantial damage. Aircraft departed Blythe Airport, CA at 1:00 am on August 1, 2016 in route to henderson, NV. Just after takeoff the aircraft did not gain altitude. The… ## Other investigations on N6728X (1) 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. - [NTSB BFO94LA117](https://openairdocs.org/ntsb/BFO94LA117), Jun 26, 1994: Beech F33A (N6728X), Quarryville, PA, substantial damage. Probable cause: THE PILOT'S FAILURE TO TOUCHDOWN AT THE PROPER POINT AND HIS DELAYED REMEDIAL ACTION. A FACTOR RELATED TO THE ACCIDENT WAS A TAILWIND. ## Docket (4 files) The files NTSB released with the investigation on November 8, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93750. 1.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446250&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Email Conversation (item 2, .PDF, 134 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446251&FileExtension=.PDF&FileName=Email%20Conversation-Master.PDF - Performance Charts Provided by Pilot (item 3, .PDF, 249 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446252&FileExtension=.PDF&FileName=Performance%20Charts%20Provided%20by%20Pilot-Master.PDF - Accident Photo (Courtesy of FAA) (item 4, .PDF, 1 photo, 153 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446253&FileExtension=.PDF&FileName=Accident%20Photo%20(Courtesy%20of%20FAA)-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.