# NTSB GAA19CA102: Beech 36, N636M, Sedona, AZ, December 19, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: December 19, 2018, 15:30 local (22:30 UTC) - Place: Sedona, AZ - Coordinates: 34.848609, -111.78833 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.8486&lon=-111.7883&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report September 26, 2019 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 98792 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA102 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98792/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98792 - Page: https://openairdocs.org/ntsb/GAA19CA102 ## Probable cause The pilot's failure to maintain the proper airspeed during landing, which resulted in the airplane landing too fast and too far down the runway to safely stop it. ## 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 A36, 43 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1151604), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech A36, 12 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=1151604), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/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 A36, 2 cases](https://openairdocs.org/ntsb-findings/03022047/cases.md?model=1151604), [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. - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Beech A36, 10 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=1151604), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Beech A36, 7 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=1151604), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Beech A36, 20 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=1151604), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech A36, 78 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151604), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that he was flying a recently purchased airplane. During initial climb, the front right cockpit door opened. He decided that the condition was unsafe and entered a left downwind to land. The approach end of the runway had rising terrain, and the airplane was too high and fast. About 200 ft above ground level, he decided to abort the landing, but the engine sputtered, and he continued the landing. The airplane overran the runway and collided with a fence. The airplane sustained substantial damage to the left wing and the elevator. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation. ## Factual narrative The pilot reported that he was flying a recently purchased airplane. During initial climb, the front right-side cockpit door opened. He decided that the condition was unsafe and entered a left downwind to land. The approach end of the runway had rising terrain, and the airplane was too high and too fast. About 200ft AGL he decided to abort the landing, but the engine sputtered. Still too fast, the airplane landed about 1,500ft down the 5,132ft runway, and he immediately applied the brakes. However, the airplane overran the runway and collided with a fence. The airplane sustained substantial damage to the left wing and the elevator. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation. ## Aircraft - Registration: [N636M](https://openairdocs.org/deregistered/N636M-2019-10-28), registration cancelled 2019-10-28, S/N E-874, built 1976 (OpenAirDocs) - Reported make and model: Beech 36 (A36) - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-550-B](https://openairdocs.org/engine/continental-io-550-b) (registry code 17208, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-874 - Year built: 1976 - Airframe hours: 4900 - Engines: Continental IO-550-B 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: 636m LLC - Registered owner: 636m LLC - Airworthiness certificate: Standard, Utility - Last inspection: Annual, April 1, 2018 - Departed: SEZ, Sedona, AZ - Destination: SEZ, Sedona, AZ - Airport: SEZ, Sedona, runway 21, 5,132 × 100 ft, asphalt - Equipment: Auto-pilot, Electronic flight bag or handheld device, Handheld GPS, Onboard weather, Stall warning system, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; injuries: none; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review August 11, 2018; seat: left; restraint: 3-point; flight hours: 11,000 total, 95 in this make and model, 150 in the last 90 days, 59 in the last 30 days, 2.5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 140° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 64 °F, dew point 30 °F - Altimeter: 30.17 inHg - Observed at: KSEZ ## 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 20181219022139A](https://openairdocs.org/incident/20181219022139A), Dec 19, 2018: Beech A36, Sedona, AZ, Substantial damage. Flight originated at hawthorne municipal (hhr), pilot stopped at sez (Sedona) for gas. While departing from sez, the door opened on climb out. A decision was… ## Other investigations on N636M (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 LAX81DVA43](https://openairdocs.org/ntsb/LAX81DVA43), May 28, 1981: Beech A36 (N636M), Bakersfield, CA, substantial damage ## Docket (3 files) The files NTSB released with the investigation on June 27, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98792. 5.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 4.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40473846&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Memorandum for Record - Pilot (item 2, .PDF, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40473847&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Pilot-Master.PDF - Photos (item 3, .PDF, 2 photos, 316 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40473848&FileExtension=.PDF&FileName=Photos-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.