GAA18CA254

NTSB accident investigation · Beech 58 · Sisters, OR · May 5, 2018

Accident · No injuriesData collectionFinal report
Date
May 4, 2018, 17:45 local (May 5, 2018, 00:45 UTC)
Place
Sisters, OR
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N222BDBeech 58
Defining event
Landing: Landing area undershoot
Weather
Visual (VMC) · Day
Status
Completed · report October 24, 2018
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA
FAA report
20180504004639A
Case key
97182

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot’s failure to maintain sufficient altitude during approach in gusting crosswind conditions, which resulted in an attempted rejected landing and a runway undershoot.

Findings · 5

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 58P: 6 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech 58P: 1 caseAll aircraft: 1,310 casesProbable cause
Performance/control parameters: descent/approach/glide pathAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech 58P: 3 casesAll aircraft: 809 casesProbable cause
Wind: gustsEnvironmental issues › Conditions/weather/phenomena · Effect on operationBeech 58P: 2 casesAll aircraft: 1,199 cases
Wind: crosswindEnvironmental issues › Conditions/weather/phenomena · Effect on operationBeech 58P: 2 casesAll aircraft: 1,008 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 performed a steep approach over tree-covered descending terrain to the tree-lined runway. He reported that, on the approach, the airplane "encountered significant low-level wind shear and sink" about 800 ft before the runway. He aborted the landing, but the airplane impacted the ground 150 ft short of the runway. The airplane sustained substantial damage to both engine mounts and the right-wing spar. The AWOS located on the airport reported that, about the time of the accident, the wind was from 250° at 13 knots, gusting to 22 knots. The density altitude was reported as 4,000 ft, and the pilot landed on runway 20, which was 3,560 ft long. The airport facility directory stated that runway 20 has a nonstandard entry due to rising terrain at the approach end, along with 81-ft-tall trees that were 560 ft from the approach end of the runway. In the recommendation section of the National Transportation Safety Board Pilot Aircraft Accident Report, the pilot reported that the accident could have been prevented by avoiding nonstandard or steep approaches to runway 20 in gusting wind conditions. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.

Factual narrative

The pilot performed a steep approach over tree-covered descending terrain to the tree lined runway. He reported that on the approach the airplane "encountered significant low-level wind shear and sink" about 800ft prior to the runway. He aborted the landing, but the airplane impacted the ground 150ft short of the runway. The airplane sustained substantial damage to the both engine mounts and the right-wing spar. The AWOS located on the airport reported that about the time of the accident, the wind was from 250° at 13 knots and gusting to 22 knots. The density altitude was reported as 4,000ft and the pilot landed to runway 20, a 3,560ft long runway. The airport facility directory states that runway 20 has a non-standard entry due to rising terrain at the approach end, along with 81ft tall trees that are 560ft from the approach end of the runway. Per the National Transportation Safety Board Pilot Aircraft Accident Report, in the Recommendation section, the pilot reported that the accident could have been prevented by avoiding non-standard or steep approaches to runway 20 in gusting wind conditions. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.

Aircraft

Registration
N222BD
Reported as
Beech 58 (P)
Category
Airplane
Serial number
TJ-409
Built
1982
Airframe hours
4,296
Engines
Continental TSIO-520-WB, 325 horsepower, reciprocatingContinental TSIO-520-WB, 325 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Operator
B2 Aviation LLC
Registered owner
B2 Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 5, 2017
Departed
APC · Napa, CA
Destination
6K5 · Sisters, OR
Airport
6K5 · Sisters Eagle Air, runway 20, 3,560 × 60 ft, asphalt
Equipment
Stall warning system, Auto-pilot, Electronic flight bag or handheld device, Electronic primary flight display, Onboard weather

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
53
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
September 19, 2017
Seat
Left
Restraint
3-point
Flight hours
2,653 total · 900 in this make and model · 241,088 as pilot in command · 58 in the last 90 days · 6 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 15 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 30 °F
Altimeter
30.15 inHg
Observed at
KRDM, 17 nm away

Docket · 3

The files NTSB released with the investigation on September 13, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.1 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.