# NTSB LAX03FA135: Beech A36, N323D, Sedona, AZ, April 13, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 13, 2003, 12:30 local (19:30 UTC) - Place: Sedona, AZ - Coordinates: 34.841388, -111.7975 - Nearby events: https://openairdocs.org/map.md?lat=34.8414&lon=-111.7975&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report October 3, 2006 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, Federal Aviation Administration, Raytheon Beech - NTSB case key (mKey): 56837 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX03FA135 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56837/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56837 - Page: https://openairdocs.org/ntsb/LAX03FA135 ## Probable cause a partial loss of engine power due to the certified flight instructor's failure to comply with the pilot operating handbook requirements for the mixture setting during takeoff. Also causal was the instructor's inadequate supervision of the flight, failure to monitor the airplane's performance, and failure to initiate an aborted takeoff in a timely way. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - nonmechanical, takeoff - roll/run - procedures/directives - not complied with, pilot in command(cfi) (cause) - mixture - improper use of, pilot in command(cfi) (cause) - Overrun, takeoff - roll/run - supervision - inadequate, pilot in command(cfi) (cause) - aircraft performance - deteriorated - aborted takeoff - not performed, pilot in command(cfi) (cause) - In flight collision with object, takeoff - object - fence - In flight collision with terrain/water, takeoff - terrain condition - dirt bank/rising embankment ## Analysis The airplane lifted off near the end of the runway, snagged the airport boundary fence, crossed a canyon, and then collided with terrain. Runway 21 was 5,132 feet long, 75 feet wide, and the airport elevation was 4,827 feet. The density altitude was calculated at 6,435 feet. Witnesses noted that the airplane did not seem to accelerate and was rolling very slowly as it passed the midfield point. The engine did not sound like it was producing much power, yet the engine tones stayed steady and the engine sounded smooth. Several of the witnesses noted that the flaps were partially down. The witnesses thought that the pilot would abort the takeoff; however, the airplane continued down the runway and was still on the ground about 80 percent of the way down the runway. Then the pilot rotated it to a takeoff attitude, and broke ground with an extremely nose high attitude. The airplane only attained an altitude of several feet. The landing gear caught the upper strands of the airport boundary fence. The airplane then collided with the far side of a canyon that bordered the airport. The operator had a form that they used for weight and balance and performance. They required pilots to complete the form prior to each flight. The form provided spaces for pilots to record pertinent data, and log computed parameters. Those parameters included takeoff weight, density altitude, runway length, rotation speed, takeoff distance, takeoff distance over a 50-foot obstacle, rate of climb, and landing distance. Calculations for the given takeoff conditions indicated that the airplane should have had a ground roll of 1,900 feet, and would clear a 50-foot obstacle at 2,100 feet. The airplane had an altitude compensating fuel pump installed. The pump would automatically lean or enrich the engine's fuel mixture as the airplane changed altitude. The before takeoff checklist in Section IV of the Pilot Operating Handbook instructed the pilot to takeoff with the mixture in the full rich position. Other instructors from the operator who had flown with the accident instructor indicated that contrary to the instructions in the POH, they all leaned the engine prior to takeoff from high density altitude airports. The spark plugs indicated operation with an excessively lean mixture. Investigators noted no other anomalies with the airframe or engine that would have precluded normal operation. ## Factual narrative HISTORY OF FLIGHT On April 13, 2003, about 1230 mountain standard time, a Beech A36, N323D, collided with a fence and then terrain during takeoff from runway 21 at Sedona, Arizona. Mesa Pilot Development, Inc., was operating the airplane under the provisions of 14 CFR Part 91. The certified flight instructor (CFI) pilot, the private pilot undergoing instruction (PUI), and one passenger sustained fatal injuries; the airplane was destroyed. The instructional cross-country flight was en route to Williams Gateway Airport, Phoenix, Arizona. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed. The primary wreckage was at 34 degrees 50.63 minutes north latitude and 111 degrees 47.69 minutes west longitude. Several witnesses observed the takeoff roll. They all noted that the airplane did not seem to accelerate and was rolling very slowly as it passed the midfield point. Several of the witnesses noted that the flaps were partially down. The witnesses thought that the pilot would abort the takeoff. However, the airplane continued down the runway and was still on the ground about 80 percent of the way down the runway. Then the pilot rotated it to a takeoff attitude. Several witnesses thought that it retained that attitude, and if it left he ground at all, it only attained an altitude of several feet. Several of the witnesses that heard the engine reported that it did not sound like it was producing much power. The engine tones stayed steady and the engine sounded smooth. It did not cough, sputter, or backfire, and none of them observed smoke or any indications of a problem. Another witness on the opposite side of the airport heard clanking and banging that sounded like a thresher machine. It was definitely not smooth or sound like engines that he had previously heard. It caught his attention and he looked toward the runway. He saw the top of a tail and fuselage. He estimated that the airplane was going about 70 miles per hour. He did not hear the engine wind down and wondered why it was trying to take off. He lost sight of the airplane behind trees and did not see it rotate. He thought that it was within 1,000 feet of the end of the runway. About 5 to 10 seconds later he heard a bang, and about 10 seconds later he heard another bang. One witness was a CFI, and an airplane mechanic with 30 years experience in general aviation. He first saw the airplane about 1/3 of the way down the runway. From the moment he saw it, he thought that something was not right. He was concerned that it was not accelerating to flying speed. The engine sounded quite different from airplanes that he had heard over his career. It sounded like it was turning very slowly, much slower than takeoff revolutions per minute (rpm). He thought that the propeller was set to cruise power rather than full rpm. It sounded like it was turning about 2,300 rpm. It sounded smooth; it did not backfire, surge, miss, or chug. It sounded the same from the time that he first saw it until it went out of sight. Other airplanes that he had observed take off had been airborne by this point. The accident airplane kept going and going. It went past the halfway point and was not accelerating. The witness kept saying, "shut down, shut down." It broke ground about 2/3 to 3/4 of the way down the runway, maybe beyond 3/4. He left his chair to watch the airplane. He noted that the nose came up and the airplane continued down the runway about 200 yards with the nose wheel off the ground and the main gear on the ground. It might have gotten airborne about 1 or 2 feet. The airplane broke ground with an extremely nose high attitude. He lost sight of it behind a parked airplane. He thought that the stall horn had to be going off. PERSONNEL INFORMATION The operator submitted a written report. CFI A review of Federal Aviation Administration (FAA) airman records revealed that the CFI held a commercial pilot certificate with ratings for airplane single engine land, multiengine land, and instrument airplane. She held a certified flight instructor certificate with ratings for airplane single engine land and instrument airplane. The CFI held a first-class medical certificate issued on May 9, 2001. It had no limitations or waivers. The operator reported that the CFI had a total flight time of 652 hours. She had 136 hours in the last 90 days, and 32 in the last 30 days. She had 50 hours in this make and model. PUI The operator reported that the PUI had a private pilot certificate with a rating for airplane single engine land. He had a total flight time of 174 hours. He had 34 hours in the last 90 days, and 14 in the last 30 days. He had 37 hours in this make and model, and was preparing for his instrument check ride. AIRCRAFT INFORMATION The airplane was a Beech A36, serial number E2613. The operator reported a total airframe time of 2,249 hours. The airplane was on a manufacturer's inspection program, and the last 100-hour inspection occurred on March 12, 2003. The tachometer read 1,748.2 and the Hobbs hour meter read 270.2 at the daily inspection prior to departure for Sedona. The engine was a Teledyne Continental Motors IO-550-B(6) engine, serial number 296594R. Time since overhaul on the engine at the last inspection was 514 hours. The operator indicated that the last fueling of the airplane occurred on April 12 with the addition of 36 gallons of aviation fuel. The airplane flew 0.8 hours on one flight prior to the accident flight. METEOROLOGICAL INFORMTION The Sedona airport administration office reported the weather conditions: skies clear; winds from 170 degrees at 11 knots gusting to 24 knots; temperature 68 degrees Fahrenheit; altimeter 30.05 inches of mercury. AIRPORT INFORMATION The Airport/ Facility Directory, Southwest U. S., indicated runway 21 was 5,132 feet long and 75 feet wide. The runway surface was asphalt, and the airport elevation was 4,827 feet. WRECKAGE AND IMPACT INFORMATION The National Transportation Safety Board investigator-in-charge (IIC) and investigators from the FAA, Beech, and Teledyne Continental Motors (TCM) examined the wreckage at the accident site on April 14, and at the facilities of Air Transport, Phoenix, on April 15. Safety Board software determined that the airplane came to rest approximately 1,032 feet on a magnetic bearing of 213 degrees from the airport. Sedona airport is on a plateau that is surrounded by rocky canyons about 500 feet deep that are sparsely covered by cedar trees and bushes. The airport boundary fence was a 6-foot-high chain link fence with angled barbed wire strands another foot high. The fence ran along the edge of a canyon that began at the end of the runway. The fence was about 150 feet from the end of the runway. It sustained mechanical damage about 100 feet right of the extended centerline. The top part of the fence was deformed and pieces of barbed wire and fence posts were on the ground on the side of the fence away from the runway. The main wreckage was on the opposite side of the canyon from the airport boundary. It was several hundred feet lower than the airport boundary fence. The first identified point of contact (FIPC) was a cedar tree with broken limbs. Another cedar tree, about 10 feet right of the FIPC as one looked toward the main wreckage, also had broken limbs. Near the base of this tree were clear Plexiglass fragments similar in shape to the wing tip recognition lights' covers. The debris path was along a magnetic bearing of 185 degrees. Thirty-three feet from the FIPC was the right main landing gear. Pieces of propeller, identified as prop piece 2 and prop piece 1, were 36 and 38 feet from the FIPC, respectfully. The principle impact crater (PIC) was 46 feet from the FIPC. A scorched area about 6 feet in diameter surrounded the PIC. The left e ## Aircraft - Registration: [N323D](https://openairdocs.org/deregistered/N323D-2008-04-14), registration cancelled 2008-04-14, S/N E2613, built 1991 (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-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E2613 - Airframe hours: 2249.1 - Engines: Teledyne Continental IO-550-B(6) 310 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Registered owner: Mesa Pilot Development, Inc. - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: 100 hour, March 12, 2003, 79.6 hours before - Departed: SEZ, SEDONA, AZ - Destination: IWA, Phoenix, AZ - Flight plan: IFR - Airport: SEZ, Sedona, runway 21, 5,132 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 34; injuries: fatal; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review August 1, 2002; seat: right; toxicology performed; flight hours: 652 total, 50 in this make and model, 553 as pilot in command, 136 in the last 90 days, 33 in the last 30 days, 1 in the last 24 hours - Student pilot; age 18; injuries: fatal; private; airplane ratings: single-engine land; medical: class 1, valid medical--w/ waivers/lim; last flight review June 1, 2002; seat: left; toxicology performed; flight hours: 174 total, 37 in this make and model, 142 as pilot in command, 34 in the last 90 days, 14 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 18 knots, gusting 24 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 57 °F, dew point 25 °F - Altimeter: 30.13 inHg - Observed at: FLG, 18 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 20030413011929A](https://openairdocs.org/incident/20030413011929A), Apr 13, 2003: Beech A36, Sedona, AZ, Destroyed, 3 fatal. (-23) During a flight that was to be an IFR training flight departing from Sedona to williams gateway a Beech bonanza A-36 was destroyed after failing to get… ## Docket (20 files) The files NTSB released with the investigation on July 15, 2006, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56837. 2.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 349 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262238&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statements (item 2, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262239&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 3, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262243&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Record of Conversation FAA Accident Coordinator (item 4, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262309&FileExtension=.PDF&FileName=Record%20of%20Conversation%20FAA%20Accident%20Coordinator-Master.PDF - Sedona Airport Report (item 5, .PDF, 11 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262252&FileExtension=.PDF&FileName=Sedona%20Airport%20Report-Master.PDF - Beech Statement (item 6, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262311&FileExtension=.PDF&FileName=Beech%20Statement-Master.PDF - Operator's Instructor's Statements (item 7, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262254&FileExtension=.PDF&FileName=Operator%27s%20Instructor%27s%20Statements-Master.PDF - TCM Fuel Pump Exam (item 8, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262255&FileExtension=.PDF&FileName=TCM%20Fuel%20Pump%20Exam-Master.PDF - Operator's Checklist (item 9, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262256&FileExtension=.PDF&FileName=Operator%27s%20Checklist-Master.PDF - Toxicological Reports (item 10, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40405523&FileExtension=.PDF&FileName=Toxicological%20Reports-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262260&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262283&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1: Runway End (item 13, .PDF, 248 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262244&FileExtension=.PDF&FileName=Photo%201%3A%20Runway%20End-Master.PDF - Photo 2: Accident Site from End of Runway (item 14, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262245&FileExtension=.PDF&FileName=Photo%202%3A%20Accident%20Site%20from%20End%20of%20Runway-Master.PDF - Photo 3: Overview of Main Wreckage (item 15, .PDF, 288 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262246&FileExtension=.PDF&FileName=Photo%203%3A%20Overview%20of%20Main%20Wreckage-Master.PDF - Photo 4: Main Wreckage to Runway (item 16, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262247&FileExtension=.PDF&FileName=Photo%204%3A%20Main%20Wreckage%20to%20Runway-Master.PDF - Photo 5: Main Wreckage Right Side (item 17, .PDF, 292 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262248&FileExtension=.PDF&FileName=Photo%205%3A%20Main%20Wreckage%20Right%20Side-Master.PDF - Photo 6: Main Wreckage Left Side (item 18, .PDF, 285 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262249&FileExtension=.PDF&FileName=Photo%206%3A%20Main%20Wreckage%20Left%20Side-Master.PDF - Photo 7: Propeller (item 19, .PDF, 267 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262250&FileExtension=.PDF&FileName=Photo%207%3A%20Propeller-Master.PDF - Photo 8: Spark Plugs (item 20, .PDF, 241 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40262251&FileExtension=.PDF&FileName=Photo%208%3A%20Spark%20Plugs-Master.PDF From the NTSB's public API. 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