# NTSB GAA20CA048: Beech A36, N9008V, Le Roy, NY, October 27, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: October 27, 2019, 15:00 local (19:00 UTC) - Place: Le Roy, NY - Coordinates: 42.981388, -77.935279 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.9814&lon=-77.9353&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: Minor injuries - Injuries: 4 minor - Status: Completed, report May 21, 2020 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 100500 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA20CA048 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100500/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100500 - Page: https://openairdocs.org/ntsb/GAA20CA048 ## Probable cause The pilot's improper pitch control during takeoff in high, gusting wind conditions, which resulted in a runway overrun and the nose landing gear collapsing. ## 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: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech A36, 1 case](https://openairdocs.org/ntsb-findings/01062022/cases.md?model=1151604), [All aircraft, 526 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md) - [Wind: high wind](https://openairdocs.org/ntsb-findings/03034055): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Beech A36, 1 case](https://openairdocs.org/ntsb-findings/03034055/cases.md?model=1151604), [All aircraft, 112 cases](https://openairdocs.org/ntsb-findings/03034055/cases.md) - [Wind: gusts](https://openairdocs.org/ntsb-findings/03034045): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Beech A36, 4 cases](https://openairdocs.org/ntsb-findings/03034045/cases.md?model=1151604), [All aircraft, 1,199 cases](https://openairdocs.org/ntsb-findings/03034045/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [Beech A36, 7 cases](https://openairdocs.org/ntsb-events/090/sequence.md?model=1151604), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) - [Takeoff: 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) - [Takeoff: 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) ## Analysis The pilot reported that, before the takeoff roll, he had increased the trim because the tail felt like it was "lifting ahead of the nose when not heavily loaded in the rear." During the takeoff roll, while about 73 knots and 1,800 ft down the runway, the airplane lifted off. The airplane was still in ground effect, and the pilot applied forward yoke pressure to increase the airspeed. He recalled checking the gauges, and all appeared within normal limits. The airplane descended to the runway about 74 knots and bounced. The airplane overran the runway, and the pilot pushed forward on the yoke to level the airplane, but the airplane encountered a wind gust from the left and touched down in the grass about 155 ft beyond the end of the runway. The nose landing gear collapsed, and the airplane stopped. The airplane sustained substantial damage to the engine mounts, the elevator, and both wings. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. ## Factual narrative The pilot reported that prior to the takeoff roll, he had increased the airplane's trim because, "the tail fells like it is lifting ahead of the nose when not heavily loaded in the rear." During the takeoff roll, about 73 knots and 1,800 ft down the runway the airplane ascended. The airplane was still in ground effect, and the pilot applied forward yoke pressure to increase the airplane's airspeed. About 1,000ft further, he noticed that the airspeed was 75 knots. He recalled checking the gauges and all appeared within normal limits. The airplane descended to the runway about 74 knots airspeed and bounced. The airplane overran the runway and he pushed forward on the yoke to level the airplane, but the airplane encountered a wind gust from the left and touched down in the grass about 155ft beyond the end of the runway. The nose landing gear collapsed, and the airplane stopped. The airplane sustained substantial damage to the engine mounts, elevator and both wings. According to the nearest METAR located 14 miles northeast of the accident site, about the time of the accident, the wind was reported as being from 260° at 17 knots and gusting to 30 knots. The pilot took off from runway 28. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. ## Aircraft - Registration: [N9008V](https://openairdocs.org/deregistered/N9008V-2021-10-30), registration cancelled 2021-10-30, S/N E-185, built 1969 (OpenAirDocs) - Reported make and model: Beech A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-185 - Year built: 1969 - Airframe hours: 7666 - Engines: Continental IO-520 285 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Public use - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 8, 2018 - Departed: 5G0, Le Roy, NY - Destination: IUA, Canandiauga, NY - Airport: 5G0, Le Roy, runway 28, 3,854 × 60 ft, asphalt - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; injuries: minor; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review September 15, 2016; seat: left; restraint: 4-point; flight hours: 285 total, 115 in this make and model, 183 as pilot in command, 11.8 in the last 90 days, 8.6 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 260° at 17 knots, gusting 30 - Visibility: 10 statute miles - Lowest ceiling: 2,900 ft broken - Temperature: 59 °F, dew point 48 °F - Altimeter: 29.70 inHg - Observed at: KROC, 14 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 20191027018939A](https://openairdocs.org/incident/20191027018939A), Oct 27, 2019: Beech A36, Leroy, NY, Substantial damage. Attempted takeoff from a paved runway/crashed in grass area at the end of the runway. Four occupants taken to hospital with unknown injuries. Flight originated… ## Docket (2 files) The files NTSB released with the investigation on January 24, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100500. 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=40480219&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Photo (item 2, .PDF, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480220&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.