GAA17CA239

NTSB accident investigation · Beech C23 · Fallon, NV · April 19, 2017

Accident · No injuriesData collectionFinal report
Date
April 19, 2017, 11:30 local (18:30 UTC)
Place
Fallon, NV
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N786KSBeech C23
Defining event
Takeoff-rejected takeoff: Loss of control on ground
Weather
Visual (VMC) · Day
Status
Completed · report July 20, 2017
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA/ FSDO
FAA report
20170419024029A
Case key
95031

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 inaccurate takeoff performance calculations and failure to maintain directional control during an aborted takeoff.

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotBeech C23: 23 casesAll aircraft: 9,295 casesProbable cause
Planning/preparation: performance calculationsPersonnel issues › Task performance · PilotBeech C23: 2 casesAll aircraft: 114 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech C23: 10 casesAll aircraft: 3,958 casesProbable cause
Runway/land/takeoff/taxi surfaceEnvironmental issues › Physical environment · Decision related to conditionBeech C23: 1 caseAll aircraft: 253 cases
Runway/land/takeoff/taxi surfaceEnvironmental issues › Physical environment · Accuracy of related infoBeech C23: 1 caseAll aircraft: 253 cases
Object/animal/substance: fence/fence postEnvironmental issues › Physical environment · Contributed to outcomeBeech C23: 4 casesAll aircraft: 313 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 two private airports were near each other, and he mistakenly landed at the wrong airport. He added that, once he realized his mistake, he referenced the Federal Aviation Administration (FAA) chart supplement and visual flight rules sectional chart and observed a published runway length of 2,600 ft for departure. The pilot reported that he referenced the Pilot's Operating Handbook (POH) and noted that the calculated takeoff distance was 1,350 ft. The pilot reported that, during the takeoff roll, he decided to abort the takeoff with about half of the runway remaining because the airplane had not reached the speed he expected. During the aborted takeoff, the airplane pulled to the left of the runway centerline "slightly" when the brakes were applied, and the left wing struck two fence posts along the runway. The collision with the fence posts pulled the airplane off the runway surface to the left and into a ditch and a barbed wire fence. The left wing sustained substantial damage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The FAA Aeronautical Information Services Office was asked by the National Transportation Safety Board investigator-in-charge to evaluate the published runway dimensions at the accident airport. Upon review, the FAA determined that the runway dimensions provided for the airport should have been 2,483 ft by 25 ft rather than 2,600 ft by 25 ft. The FAA submitted the revised dimensions to the National Flight Data Center for publication. According to takeoff performance calculations with the FAA Koch Chart, the airplane would have likely experienced a 60% increase to the normal takeoff distance. When factoring in this increase with the airplane's POH takeoff distance chart, the ground roll required was about 1,808 ft, and the total distance to clear a 50-ft obstacle was 3,128 ft. Numerous trees were located at the end of the runway. The distance to clear the 50-ft obstacle exceeded the published runway length and revised runway length.

Factual narrative

The pilot reported that two private airports were in close proximity to one another, and he mistakenly landed at the wrong airport. He added that once he realized his mistake, he referenced the Federal Aviation Administration (FAA) chart supplement and visual flight rules (VFR) sectional chart and observed a published runway length of 2,600 ft. for departure. The pilot reported that he referenced the pilot's operating handbook (POH) and noted that the calculated takeoff distance was 1,350 ft. The pilot reported that during the takeoff roll, he decided to abort the takeoff with about half of the runway remaining, because the airplane had not reached the speed he expected. During the aborted takeoff, the airplane pulled to the left of the runway centerline "slightly" when the brakes were applied, and the left wing struck two fence posts along the runway. The collision with the fence posts pulled the airplane off the runway surface to the left and into a ditch and a barbed wire fence. The left wing sustained substantial damage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The FAA Aeronautical Information Services Office was asked by the National Transportation Safety Board investigator-in-charge to evaluate the published runway dimensions at the accident airport. Upon review, the FAA determined the runway dimensions provided for the airport should have been 2,483 ft. x 25 ft., rather than 2,600 ft. x 25 ft. The FAA submitted the revised dimensions to the National Flight Data Center for publication. According to takeoff performance calculations with the FAA Koch Chart, the airplane would have likely experienced a 60% increase to the normal takeoff distance. When factoring in this increase with the airplane's POH takeoff distance chart, the ground roll required was about 1,808 ft. and the total distance to clear a 50 ft. obstacle was 3,128 ft. Numerous trees were located at the end of the runway. The distance to clear the 50 ft. obstacle exceeded the published runway length and revised runway length.

Aircraft

Registration
N786KS
Reported as
Beech C23 (NO SERIES)
Category
Airplane
Serial number
M-1676
Built
1975
Airframe hours
6,505
Engine
Lycoming O-360-A4K, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 1, 2016
Departed
FLX · Fallon, NV
Destination
1NV1 · Fallon, NV
Airport
26NV · Darrow Field, runway 16, 2,483 × 25 ft, asphalt
Equipment
None

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
58
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Seat
Left
Flight hours
91 total · 91 in this make and model · 70 as pilot in command · 19 in the last 90 days · 7 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 9 knots
Visibility
10 statute miles
Temperature
59 °F, dew point 37 °F
Altimeter
30.15 inHg
Observed at
KNFL, 6 nm away

Docket · 6

The files NTSB released with the investigation on June 22, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.3 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.