# NTSB GAA17CA239: Beech C23, N786KS, Fallon, NV, April 19, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: April 19, 2017, 11:30 local (18:30 UTC) - Place: Fallon, NV - Coordinates: 39.453056, -118.866386 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.4531&lon=-118.8664&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff-rejected takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report July 20, 2017 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA/ FSDO - NTSB case key (mKey): 95031 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA17CA239 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95031/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95031 - Page: https://openairdocs.org/ntsb/GAA17CA239 ## Probable cause The pilot's inaccurate takeoff performance calculations and failure to maintain directional control during an aborted takeoff. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech C23, 23 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1151242), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Planning/preparation: performance calculations](https://openairdocs.org/ntsb-findings/02061010): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech C23, 2 cases](https://openairdocs.org/ntsb-findings/02061010/cases.md?model=1151242), [All aircraft, 114 cases](https://openairdocs.org/ntsb-findings/02061010/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech C23, 10 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=1151242), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Runway/land/takeoff/taxi surface](https://openairdocs.org/ntsb-findings/03023000): Environmental issues › Physical environment · Decision related to condition; cases with it: [Beech C23, 1 case](https://openairdocs.org/ntsb-findings/03023000/cases.md?model=1151242), [All aircraft, 253 cases](https://openairdocs.org/ntsb-findings/03023000/cases.md) - [Runway/land/takeoff/taxi surface](https://openairdocs.org/ntsb-findings/03023000): Environmental issues › Physical environment · Accuracy of related info; cases with it: [Beech C23, 1 case](https://openairdocs.org/ntsb-findings/03023000/cases.md?model=1151242), [All aircraft, 253 cases](https://openairdocs.org/ntsb-findings/03023000/cases.md) - [Object/animal/substance: fence/fence post](https://openairdocs.org/ntsb-findings/03022047): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Beech C23, 4 cases](https://openairdocs.org/ntsb-findings/03022047/cases.md?model=1151242), [All aircraft, 313 cases](https://openairdocs.org/ntsb-findings/03022047/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 C23, 3 cases](https://openairdocs.org/ntsb-events/030/sequence.md?model=1151242), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Takeoff-rejected takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Beech C23, 9 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=1151242), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Takeoff-rejected takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech C23, 25 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151242), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Takeoff-rejected takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Beech C23, 9 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=1151242), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## 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](https://openairdocs.org/deregistered/N786KS-2019-07-09), registration cancelled 2019-07-09, S/N M-1676, built 1975 (OpenAirDocs) - Reported make and model: BEECH C23 (NO SERIES) - Registry model: [Beech C23](https://openairdocs.org/model/beech-c23) (registry code 1151242) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: M-1676 - Year built: 1975 - Airframe hours: 6505 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: none; 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 ## 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 20170419024029A](https://openairdocs.org/incident/20170419024029A), Apr 19, 2017: Beech C23, Fallon, NV, Substantial damage. The pilot landed at 26NV, a private airfield. After landing, he attempted to depart a short time later. He aborted the take off roll mid field, and veered to… ## Docket (6 files) The files NTSB released with the investigation on June 22, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95031. 3.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40453616&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation (Pilot in Command) (item 2, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40453617&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(Pilot%20in%20Command)-Master.PDF - Record of Conversation (Airport Manager) (item 3, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40453618&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(Airport%20Manager)-Master.PDF - Airport Runway Information NTSB (item 4, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40453619&FileExtension=.PDF&FileName=Airport%20Runway%20Information%20NTSB-Master.PDF - Performance Information NTSB (item 5, .PDF, 432 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40453620&FileExtension=.PDF&FileName=Performance%20Information%20NTSB-Master.PDF - Accident Photos (Courtesy of FAA) (item 6, .PDF, 2 photos, 417 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40453621&FileExtension=.PDF&FileName=Accident%20Photos%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.