# NTSB LAX93LA370: Beech A-36, N7246Z, Firebaugh, CA, September 25, 1993 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 25, 1993, 14:30 local (21:30 UTC) - Place: Firebaugh, CA - Coordinates: 36.849178, -120.539657 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.8492&lon=-120.5397&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report September 26, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 28490 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX93LA370 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28490/pdf - Page: https://openairdocs.org/ntsb/LAX93LA370 ## Probable cause the CFI's inadequate supervision of the flight and his delay in taking remedial action; the dual student's premature liftoff and improper use of the flight controls. The high vegetation and soft terrain were factors in this accident. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - lift-off - premature, dual student (cause) - flight controls - improper use of, dual student (cause) - stall/mush - inadvertent, pilot in command(cfi) (contributing factor) - supervision - inadequate, pilot in command(cfi) (cause) - remedial action - delayed, pilot in command(cfi) (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - high vegetation (contributing factor) - terrain condition - soft (contributing factor) ## Analysis THE PRIVATE PILOT/OWNER WAS TAKING PART IN A FLIGHT PROFICIENCY CLINIC. AT THE TIME OF THE ACCIDENT, THE PILOT WAS RECEIVING DUAL INSTRUCTION FROM A CERTIFIED FLIGHT INSTRUCTOR. AFTER LANDING AT THE AIRPORT AND WHILE TAXIING BACK TO THE LANDING RUNWAY THRESHOLD, THE CFI INSTRUCTED THE PILOT TO EXECUTE A SOFT FIELD TAKEOFF. THE PILOT DOES NOT HAVE ANY INDEPENDENT RECOLLECTION IF HE HAD RETRIMMED THE AIRPLANE BUT PROCEEDED TO EXECUTE THE SOFT FIELD TAKEOFF. ON LIFT-OFF THE AIRPLANE'S STALL WARNING ACTIVATED AND THE AIRPLANE BEGAN TO SETTLE. THE CFI ASSUMED THE FLIGHT CONTROLS. THE AIRPLANE STRUCK THE GROUND AND EXITED THE RUNWAY. THE NOSE GEAR BECAME ENTANGLED WITH THE 3 - 4 FT HIGH WEEDS ADJACENT TO THE RUNWAY. ## Factual narrative On September 25, 1993, at 1430 hours Pacific daylight time, a Beech A-36, N7246Z, collided with terrain at Firebaugh Airport, Firebaugh, California. The pilots were conducting a local visual flight rules instructional flight. The airplane, registered to and operated by the certificated private pilot receiving instruction, herein referred to as the dual student, sustained substantial damage. Neither the certificated airline transport pilot/flight instructor (CFI) nor the dual student were injured. Visual meteorological conditions prevailed. The flight originated at Fresno Air Terminal, Fresno, California, at 1230 hours. Mr. Robert Follet, Wofford Flying Service, Fresno, California, told Safety Board investigators that the dual student was performing a soft field takeoff at the time of the accident. The airplane lifted off and then the stall warning horn activated. The airplane began to settle and the CFI took the controls to arrest the stall/mush, but without success. The airplane struck the ground and exited the runway. The dual student submitted the required Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2, together with a Statement of Incident. In the statement, he reported that the flight was part of a Bonanza Society Flight Proficiency Class which was conducted over a three-day period. Certified flight instructors provided ground and flight training for the participants. While in the practice area, the CFI instructed the pilot to perform various maneuvers. The flight then proceeded to Los Banos Airport where the dual student performed normal and short field takeoffs and landings and then flew to Firebaugh Airport. After landing at Firebaugh, the dual student returned to the departure end of the landing runway. When the airplane approached the runway threshold, while still on the taxiway, the CFI instructed the dual student execute a soft field takeoff. When approaching the hold short line, the dual student applied full power and pulled back on the yoke and turned onto the runway. The dual student then said, "The airplane appeared to be a little left of center line with a nose up attitude." Almost immediately the CFI then said, "It's my plane, I have the plane." The airplane continued down the runway in a nose-up attitude and it drifted to the right of the centerline. The CFI pushed the nose down, but the airplane had already exited the runway and the nose gear became entangled with weeds between three and four feet high. The CFI reportedly told the dual student immediately after the accident that, "I am sorry this happened Ernie, since I am pilot-in-command, I take full responsibility for this." Mr. Jim Hallows, Aviation Safety Inspector (Operations), Fresno Flight Standards District Office, reported that he administered a reexamination of the CFI on October 20, 1993. The CFI told him that he was pilot-in-command during the referenced accident flight. The CFI also stated that "he had just let things go too far before attempting to take corrective action." The CFI did not file the Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2, as required by Title 49 CFR 830. ## Aircraft - Registration: [N7246Z](https://openairdocs.org/aircraft/N7246Z), registered now, S/N E-2266, built 1985 (OpenAirDocs) - Reported make and model: BEECH A-36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Airplane - Serial number: 2266 - Airframe hours: 515 - Engines: CONTINENTAL IO-550 300 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Registered owner: Earnest Camacho - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: Continuous airworthiness, November 1, 1992, 515 hours before - Airport: Q49, Firebaugh ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; commercial, airline transport, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; flight hours: 231 total, 140 in this make and model, 160 as pilot in command, 30 in the last 90 days, 12 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Visibility: 30 statute miles - Lowest ceiling: none - Temperature: 99 °F ## 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 19930925036299A](https://openairdocs.org/incident/19930925036299A), Sep 25, 1993: Beech A36, Firebaugh, CA, Substantial damage. CFI advised student make soft field takeoff. Nose high running takeoff ensued.CFI too over too late. Stall mushed. 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.