IAD03FA050

NTSB accident investigation · Beech A36 · Jackson, OH · April 26, 2003

Accident · FatalField investigationFinal report
Date
April 26, 2003, 16:30 local (20:30 UTC)
Place
Jackson, OH
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N523BLBeech A36
Weather
Visual (VMC) · Day
Status
Completed · report April 28, 2004
Report
Approved by Office Director
Parties
Teledyne Continental Motors, FAA/FSDO, Raytheon Aircraft Company
FAA report
20030426010169A
Case key
56889

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 flight instructor's improper decision to turn back to the airport at an insufficient altitude after takeoff and his failure to maintain adequate airspeed, during a simulated engine failure.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightTakeoff - initial climb
Emergency procedure - simulatedPilot in command(cfi)
Planning/decision - improperPilot in command(cfi)Cause
Airspeed - inadequatePilot in command(cfi)Cause
Stall/spin - inadvertentPilot in command(cfi)
In flight collision with objectDescent - uncontrolled
Object - tree(s)

Analysis

Witnesses heard the pilot announce over the UNICOM frequency that he would be performing a simulated engine failure after takeoff from runway 01, returning to land on runway 19. Several witnesses observed the airplane depart from runway 01, and enter a "nose-high" climb attitude, until the airplane "stalled," and descended straight-down. One witness observed the airplane enter a stall, and then a continual right bank turn until it impacted trees. Examination of the airplane revealed no mechanical deficiencies. According to a pilot who flew with the instructor on the morning of the accident, one of the maneuvers which the instructor emphasized was an emergency landing after takeoff. The pilot stated that they practiced this maneuver twice; once at an altitude of 900 feet, and once at 1,000 feet. After the instructor pulled the power back at the desired altitude, the pilot would pitch the airplane for the "best glide speed," or 80 knots, and bank the airplane "real hard," into a 45-degree bank to return to the airport. Examination of the Beechcraft Pilot Proficiency Program Flight Instructor's Teaching Guide stated that a turn back after power loss on takeoff, should be performed at a minimum altitude of 1,200 feet AGL, and 1.7 to 1.9 nm upwind from the start of a climb. A review of FAA-H-8083-3, Airplane Flying Handbook, revealed: "...If an actual engine failure should occur immediately after takeoff and before a safe maneuvering altitude is attained, it is usually inadvisable to attempt to turn back to the field from where the takeoff was made. Instead, it is safer to immediately establish the proper glide attitude, and select a field directly ahead or slightly to either side of the takeoff path."

Factual narrative

History of flight

On April 26, 2003, about 1630 eastern daylight time, a Beech A36, N523BL, was substantially damaged when it impacted trees during a descent after takeoff from James A. Rhodes Airport (I43), Jackson, Ohio. The certified flight instructor and the private pilot were fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the instructional flight conducted under 14 CFR Part 91.

The accident flight occurred during a Beechcraft Pilot Proficiency Program (BPPP), being conducted over a 3-day period at Port Columbus International Airport (CMH), Columbus, Ohio. According to the president of the program, the purpose of the program was to pair pilot/owners of Beechcraft airplanes with instructors employed by BPPP, for the purpose of ground and flight training.

The private pilot had attended an all-day ground school the day prior to the accident, and was scheduled for a flight period from 1300-1700, with the instructor, on the afternoon of April 26. At the completion of the flight, the pilot was to receive his biennial flight review.

Several witnesses observed the airplane in the traffic pattern at Jackson. One witness reported that a pilot from the accident airplane announced over the UNICOM frequency that he was inbound to the airport on the GPS Runway 01 approach. The witness observed the airplane touchdown "smoothly" and back-taxi to runway 01. The pilot then announced over the Unicom that he would perform a takeoff from runway 01, northbound. The airplane departed the runway, then performed a 180-degree turn to land on runway 19. The airplane taxied to the approach end of runway 01, and a pilot announced over the Unicom that they would be performing a "simulated emergency landing" after takeoff.

The witness observed the "smooth, level takeoff," and noted that the engine was "really humming," and appeared to be at "full power." The airplane was in a "nose-up" attitude during the climb, and reached an altitude of about 1,200-1,300 feet [AGL] before it pitched down and impacted trees.

A second witness, who was a flight instructor at the airport, was located in the terminal building when he first observed the airplane back taxiing on runway 01. The airplane made a "normal" takeoff from runway 01, then returned to land on runway 19. The airplane again back-taxied to runway 01 and the witness keyed the Unicom microphone to inform the pilot of wind conditions from the north-northeast, at 3-5 knots. The pilot thanked the witness for reporting the winds and stated that he intended to take off from runway 01, and "do a simulated return to land on one nine."

The witness observed the airplane depart, then turned his attention away from it. When the witness looked back at the airplane, it was about 200 feet above the tree line, "descending vertically and rotating."

A third witness, who observed the airplane during its second takeoff climb, stated that it appeared the airplane "entered a stall," and its nose "dropped" into a continual right bank turn until it impacted trees. The witness also reported the engine was "solid-sounding" and he heard no interruption of power.

The accident occurred during the hours of daylight at 39 degrees, 07 minutes north latitude, and 77 degrees, 34 minutes west longitude.

Personnel information

The pilot/owner of the airplane held a private pilot certificate with ratings for airplane single engine land and instrument airplane. Examination of his logbook revealed he had 405.4 hours of total flight experience, of which, 327.5 hours were in make and model. The pilot's most recent Federal Aviation Administration (FAA) third class medical certificate was issued on July 29, 2002.

The flight instructor held an airline transport pilot certificate, and was a certified instrument flight instructor for single and multi engine land. According to the latest flight instructor history form provided by the BPPP, the pilot had 7,300 hours of total flight experience, of which, 500 to 800 hours were in a similar make and model airplane. He also reported 3,000 hours of instruction time. The flight instructor's most recent FAA second class medical certificate was issued on April 12, 2002.

Aircraft information

According to fuel records provided by a fixed base operator at Port Columbus Airport, the airplane was refueled on April 26, 2003, with 12 gallons of 100 low lead aviation fuel.

Examination of the airplane logbooks revealed the last annual inspection was completed on August 21, 2002, at a tachometer time of 912 hours.

Meteorological information

Weather, reported at Tri-State Airport/Milton J. Ferguson Field (HTS), Huntington, West Virginia, 40 miles south of Jackson, at 1551, included light and variable winds at 3 knots, 10 miles visibility, a broken cloud layer at 4,400 feet, another broken cloud layer at 4,900 feet, temperature 63 degrees Fahrenheit, dew point 52 degrees Fahrenheit, and barometric pressure of 29.76 inches Hg.

Wreckage and impact information

The accident site was located in a densely wooded area, about 1 mile north of the departure end of runway 01, on the extended runway centerline. The initial impact point was a tree-strike about 15 feet above the ground, on a 35-foot tall tree. At the base of the tree was a 12-foot section of the leading edge of the right wing. Two additional tree strikes were noted prior to the main wreckage; however, no other trees in the surrounding area were disturbed. The broken ends of the tree strikes exhibited 45-degree cuts and some paint transfer. The impact angle through the trees was estimated to be about 60-degrees.

The wreckage path was oriented on a heading of 252 degrees magnetic and extended about 20 feet from the initial impact point to the main wreckage. The airplane came to rest upright, on a heading of 005 degrees magnetic, with all components accounted for in the immediate vicinity of the wreckage.

The main fuselage remained intact; however, severe aft crushing was noted in the cockpit area, exposing internal wiring and the right side of the instrument panel. The instrument panel was displaced into the engine firewall, and the engine had partially separated from the firewall, coming to rest on a heading of 090 degrees magnetic. The three-bladed propeller remained attached to the engine at the propeller hub. Two of the blades exhibited slight torsional bending, and one blade was bent and folded under the engine. Each of the blades exhibited chordwise scratching.

The rear portion of the right wing remained attached to the fuselage at the wing root, and the forward section of the wing was crushed aft to the main spar.

The left wing remained attached to the fuselage at the wing root and impact damage was noted on the leading edge.

The empennage remained attached to the fuselage; however, a tear was noted in the empennage section, just aft of the rear cabin seats, which encircled most of the empennage. Both the rudder and horizontal stabilizer remained intact and attached to the vertical stabilizer at their attachment points.

All flight controls remained attached at their respective attachment points and flight control continuity was confirmed from the flight controls to the cockpit. The landing gear and flaps were observed in the retracted positions, and measurements taken of their respective actuators confirmed the position.

Both fuel tanks were breached; however, the fuel caps were secured to the tanks. A slight odor of fuel was present at the scene, and emergency personnel observed fuel on the ground in the vicinity of the right wing. The fuel selector exhibited impact damage, and its position could not be determined. The fuel screen was absent of debris. Fuel was observed in the fuel line leading to the fuel distributor. The fuel was absent of debris and appeared blue in color.

The engine was removed from th

Aircraft

Registration
N523BL
Reported as
Beech A36
Category
Airplane
Serial number
E-3194
Airframe hours
977.5
Engine
Continental IO-550, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Registered owner
Wesley Vance
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 21, 2002 · 65.5 hours before
Departed
I43 · Jackson, OH
Destination
I43 · Jackson, OH
Airport
I43 · James Rhodes Airport, runway 01, 5,201 × 75 ft, asphalt

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
49
Injuries
Fatal
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Right
Toxicology
Performed
Flight hours
7,300 total · 650 in this make and model
Role
Pilot
Age
45
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Last flight review
June 10, 2001
Seat
Left
Toxicology
Performed
Flight hours
405 total · 319 in this make and model · 365 as pilot in command · 12 in the last 90 days · 5 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 3 knots
Visibility
10 statute miles
Lowest ceiling
4,400 ft broken
Temperature
63 °F, dew point 52 °F
Altimeter
29.76 inHg
Observed at
HTS, 37 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.