# NTSB GAA18CA254: Beech 58, N222BD, Sisters, OR, May 5, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: May 4, 2018, 17:45 local (May 5, 2018, 00:45 UTC) - Place: Sisters, OR - Coordinates: 44.304443, -121.539169 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.3044&lon=-121.5392&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Landing area undershoot](https://openairdocs.org/ntsb-events/370) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report October 24, 2018 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 97182 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA18CA254 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97182/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97182 - Page: https://openairdocs.org/ntsb/GAA18CA254 ## 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 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 58P, 6 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1152744), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech 58P, 1 case](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=1152744), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech 58P, 3 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=1152744), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Wind: gusts](https://openairdocs.org/ntsb-findings/03034045): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Beech 58P, 2 cases](https://openairdocs.org/ntsb-findings/03034045/cases.md?model=1152744), [All aircraft, 1,199 cases](https://openairdocs.org/ntsb-findings/03034045/cases.md) - [Wind: crosswind](https://openairdocs.org/ntsb-findings/03034040): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Beech 58P, 2 cases](https://openairdocs.org/ntsb-findings/03034040/cases.md?model=1152744), [All aircraft, 1,008 cases](https://openairdocs.org/ntsb-findings/03034040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Other weather encounter](https://openairdocs.org/ntsb-events/400); cases with it: [Beech 58P, 1 case](https://openairdocs.org/ntsb-events/400/sequence.md?model=1152744), [All aircraft, 1,127 cases](https://openairdocs.org/ntsb-events/400/sequence.md) - [Landing: Landing area undershoot](https://openairdocs.org/ntsb-events/370) (defining event); cases with it: [Beech 58P, 1 case](https://openairdocs.org/ntsb-events/370/sequence.md?model=1152744), [All aircraft, 201 cases](https://openairdocs.org/ntsb-events/370/sequence.md) ## 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](https://openairdocs.org/deregistered/N222BD-2020-10-31), registration cancelled 2020-10-31, S/N TJ-409, built 1982 (OpenAirDocs) - Reported make and model: BEECH 58 (P) - Registry model: [Beech 58P](https://openairdocs.org/model/beech-58p) (registry code 1152744) (OpenAirDocs) - Category: Airplane - Serial number: TJ-409 - Year built: 1982 - Airframe hours: 4296 - Engines: Continental TSIO-520-WB 325 horsepower reciprocating; Continental 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; injuries: none; 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 ## 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 20180504004639A](https://openairdocs.org/incident/20180504004639A), May 4, 2018: Beech 58P, Sisters, OR, Substantial damage. Aircraft was flying from nappa, California (kapc), returning to Sisters, Oregon (6K5). On short final to runway 20 aircraft encountered a low level wind shear… ## Docket (3 files) The files NTSB released with the investigation on September 13, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97182. 4.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466674&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Sisters Eagle Air Airport - AWOS Data (item 2, .PDF, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466675&FileExtension=.PDF&FileName=Sisters%20Eagle%20Air%20Airport%20-%20AWOS%20Data-Master.PDF - Photo (item 3, .PDF, 1 photo, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466676&FileExtension=.PDF&FileName=Photo-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.