# NTSB LAX96LA191: Beech A36, N100YJ, Page, AZ, May 7, 1996 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: May 7, 1996, 11:48 local (18:48 UTC) - Place: Page, AZ - Coordinates: 36.680786, -111.410751 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.6808&lon=-111.4108&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 2 minor, 1 uninjured - Status: Completed, report January 17, 1997 - Report: Approved by Office Director - NTSB case key (mKey): 29435 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX96LA191 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/29435/pdf - Page: https://openairdocs.org/ntsb/LAX96LA191 ## Probable cause the pilot's inadequate compensation for a gusty crosswind condition, and his failure to obtain and maintain an adequate airspeed during the takeoff initial climb in a high density altitude situation, which resulted in an inadvertent stall/mush. Related factors were: the pilot's improper preflight by failing to secure the door, his diverted attention with the door opening at rotation, and the use of the air conditioner during takeoff. ## 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 - weather condition - crosswind - weather condition - gusts - compensation for wind conditions - inadequate, pilot in command (cause) - weather condition - turbulence,terrain induced - weather condition - high density altitude - door,passenger - not secured - aircraft preflight - improper, pilot in command (contributing factor) - diverted attention, pilot in command (contributing factor) - airspeed - not obtained/maintained, pilot in command (cause) - stall/mush - inadvertent, pilot in command - In flight collision with terrain/water, descent - uncontrolled - terrain condition - dirt bank/rising embankment ## Analysis The pilot reported that the passenger door came open during takeoff in a crosswind condition that was gusting to 21 knots. The density altitude was 6,950 feet, and the runway in use sloped uphill 1.22 percent. The pilot said that a tremendous gust caused him to crash about 600 feet beyond the departure end of the runway. Witnesses observed the aircraft takeoff in a nose high attitude and settle back to the runway once or twice before disappearing off the end of the runway. An FAA inspector reported that there were skid marks on the runway where the aircraft lifted off, showing that it drifted to the left while yawed to the right. The inspector also reported that he found the landing gear extended and the air conditioner switch in the 'on' position. According to the Airplane Flight Manual, the air conditioner must be 'off' for takeoff. ## Factual narrative On May 7, 1996, at 1148 hours mountain standard time, a Beech A36, N100YJ, collided with a dirt embankment during initial climb after takeoff at Page, Arizona, and was destroyed. The pilot and one passenger received minor injuries, one passenger was seriously injured, and the other passenger was not injured. The flight was destined for Las Vegas, Nevada. Visual meteorological conditions prevailed and no flight plan was filed. The airport manager told the NTSB investigator that the aircraft departed on runway 15 (5,499 feet long, 150 feet wide, upslope gradient 1.22 percent). The temperature was 85 degrees Fahrenheit, and the surface wind was from the southwest at 10 knots with gusts to 21 knots. The airport elevation is 4,310 feet (density altitude 6,950 feet). According to the airport UNICOM operator who watched the aircraft depart, the aircraft became airborne about 2,000 feet from the end of the runway, the wings wobbled, and the aircraft settled back onto the runway once. The aircraft then became airborne again and disappeared below the departure end. The aircraft came to rest approximately 600 feet from the departure end and 200 feet right of the runway extended centerline. Another aircraft, a twin-engine Aerostar, was traveling with the accident aircraft and took off on runway 15 immediately before the accident. The pilot of that aircraft reported that there was a strong quartering crosswind from the right and turbulence over the departure end of the runway. He reported a perceptible performance degradation in his aircraft due to density altitude. He also said that the three passengers in the Bonanza were small (light weight) people, their baggage was light, and the Bonanza had fueled to capacity before leaving Las Vegas the previous day. The passenger who had been seated in the right front seat of the accident aircraft stated that windy conditions prevailed with strong gusts. The pilot made a point to her that he was going to use the full length of the runway for takeoff. During the takeoff roll the door on her right came open, and she and the passenger in the right rear seat held onto it. She said that the pilot was "working to control" the aircraft and "working to straighten us out" immediately before the accident. In his accident report, the pilot stated that there was no mechanical malfunction of the aircraft except the door coming open. As he started a gentle right turn to return for landing (to close the door), they encountered a strong gust and then a tremendous gust. The pilot reported that "All I could do at that point was try to keep the wings level". An inspector from the FAA's Scottsdale (Arizona) Flight Standards District Office reported that witnesses told him the aircraft lifted off in a nose-high attitude and settled back onto the runway twice. The inspector found tire skid marks on the runway where the aircraft lifted off showing the aircraft drifting to the left while yawed to the right. In the wreckage the air conditioner switch was on and the landing gear down. The Airplane Flight Manual requires that the air conditioner be off for takeoff. According to the FSDO inspector the aircraft was approximately 600 pounds under gross weight. The engine was removed from the aircraft and shipped to the Teledyne Continental Motors facility in Mobile, Alabama, where it was installed and run on a test stand. The engine developed a corrected output of 302.4 horsepower. ## Aircraft - Registration: [N100YJ](https://openairdocs.org/deregistered/N100YJ-1996-11-01), registration cancelled 1996-11-01, S/N E1790 (OpenAirDocs) - Reported make and model: Beech A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Category: Airplane - Serial number: E-1790 - Airframe hours: 2464 - Engines: Continental IO-550-B(1) 300 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Sherman B. Given - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 7, 1995, 69 hours before - Departed: PGA - Destination: LAS, LAS VEGAS, NV - Airport: PGA, Page Municipal, runway 15, 5,500 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 77; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 1,915 total, 1,672 in this make and model, 1,706 as pilot in command, 33 in the last 90 days, 14 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 21 knots, gusting 28 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 14 °F - Altimeter: 30.00 inHg - Observed at: GCN, 68 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 19960507009559A](https://openairdocs.org/incident/19960507009559A), May 7, 1996: Beech A36, Page, AZ, Destroyed. Unable climb on liftoff. Settled twice. Door opened. Impacted dirt bank. Upslope density alt. Airconditioner factor 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.