# NTSB LAX01LA095: Beech A36, N3191A, Palo Alto, CA, February 9, 2001 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: February 9, 2001, 14:12 local (22:12 UTC) - Place: Palo Alto, CA - Coordinates: 37.449291, -122.100608 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.4493&lon=-122.1006&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report November 28, 2001 - Report: Approved by Office Director - Parties: AWP-SJC-FSDO, Rolls-Royce Corporation, Hartzell Propeller Inc. - NTSB case key (mKey): 51721 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX01LA095 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/51721/pdf - Page: https://openairdocs.org/ntsb/LAX01LA095 ## Probable cause The pilot-in-command's delayed decision to go-around and his failure to maintain sufficient airspeed during the attempted go-around. His non-verification of the flap setting contributed to the accident. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, go-around (vfr) - weather condition - crosswind - flaps - not verified, pilot in command (contributing factor) - in-flight planning/decision - delayed, pilot in command (cause) - airspeed - low, pilot in command (cause) ## Analysis The airplane's right wing struck the ground and the airplane came to rest on the runway following a loss of control on an attempted go-around. The pilot had received 107.9 hours of dual instruction and was making his first solo flight in the airplane. The purpose of the flight was to practice takeoffs and landings. The pilot selected approach flaps on downwind but never checked their position. On short final, the pilot sensed his descent rate was too great and attempted a go-around. The airplane drifted towards the left and then rolled right continuing to descend until it struck the ground. Postcrash examination of the engine and propeller revealed impact damage that was consistent with the propeller having contacted the ground in a high airplane pitch attitude, and a propeller blade angle consistent with a "power on" condition. ## Factual narrative On February 9, 2001, at 1412 hours Pacific standard time, a Beech A36, N3191A, sustained substantial damage when the it struck the ground during an attempted go-around at the Palo Alto, California, airport. The private pilot operated the airplane under the provisions of 14 CFR Part 91, and was not injured. The personal local flight departed approximately 1400. Visual meteorological conditions prevailed, and no flight plan had been filed. When interviewed by National Transportation Safety Board investigators, the pilot stated that his intention was to practice takeoffs and landings. He extended downwind for spacing on a slower airplane, and recalls selecting approach flaps but does not recall checking the position of the flaps. The final approach was stable at 80 knots but when he was about 10 feet off the ground he sensed the airplane was sinking faster than normal and elected to go around. He added power but did not feel the engine respond. The airplane veered left and the left wing struck the ground, the left gear was sheared off, and the propeller was torn off the engine. The pilot said that after examining the airplane the flaps appeared to be up. The airplane, equipped with a Rolls-Royce Model 250-B17F/2 Turboprop engine, had been purchased in August 2000. The pilot had received dual instruction in the airplane but his insurance carrier required he hold an instrument rating prior to acting as pilot-in-command. His instrument rating was received February 7, 2001. The pilot had received 107.9 hours of dual instruction in the airplane and the accident flight was his first solo flight in type. A representative of Rolls-Royce Corporation participated in the investigation. No engine discrepancies were noted. However, the beta valve tie rod was displaced from the rod end connector. No signs of safety wire or damaged threads on the tie rod or rod end were noted. Upon removing the engine oil filter housing, no filter was found. It was noted that the compressor received leading edge damage to all first stage blades. Also, fuel control and fuel nozzle tests indicated no signs of malfunction. A representative of Hartzell Propeller, Inc., the manufacturer of the propeller, participated in the investigation. The propeller blades were found in a high pitch/feather position. The piston had a clear impact mark, about 25 degrees blade angle. The representative explained that this is a realistic blade angle for a "power on" impact. The representative concluded that this mark indicated that the piston was at 25 degrees, or lower, blade angle prior to impact because the blades were driven to feather as a result of impact damage. He also found that the engine-mounted beta valve link arm was disconnected and the lockwire was missing from the jam nut. A pilot taxiing on a taxiway parallel to the runway witnessed the accident. He stated that he saw the airplane flare approximately one wingspan's height above the runway and begin drifting to the left. The airplane continued drifting to the left in a very nose-high attitude. It drifted over the taxiway about 40 feet agl. The drift stopped and the right wing dropped. The right wing hit the grass between the taxiway and the runway and the airplane spun around and stopped on the runway. ## Aircraft - Registration: [N3191A](https://openairdocs.org/aircraft/N3191A), registered now, S/N E-3291, built 1999 (OpenAirDocs) - Reported make and model: Beech A36 - Registry model: [Raytheon A36](https://openairdocs.org/model/raytheon-a36) (registry code 7150001) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E3291 - Airframe hours: 119 - Engines: Rolls-Royce 250-B17F/2 450 horsepower turbo prop - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Eliezer Pasternak - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 21, 2000, 107 hours before - Departed: PAO, Palo Alto, CA - Airport: PAO, Palo Alto Arpt Of Santa Clara, runway 31, 2,500 × 65 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: none; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; last flight review February 7, 2000; seat: left; flight hours: 619 total, 108 in this make and model, 499 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 6 knots - Visibility: 7 statute miles - Lowest ceiling: 3,000 ft broken - Temperature: 50 °F, dew point 43 °F - Altimeter: 29.89 inHg - Observed at: PAO ## 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 20010209002279A](https://openairdocs.org/incident/20010209002279A), Feb 9, 2001: Beech A36, Palo Alto, CA, No damage. (.19) On 2/09/ 2001 at 1412 hours pacific standard time, a Beech A36, N3191A, sustained substantial damage when the left wing struck the ground during an… 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.