# NTSB NYC05FA006: Beech H50, N171S, Hartwood, VA, October 17, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 17, 2004, 14:00 local (18:00 UTC) - Place: Hartwood, VA - Coordinates: 38.48722, -77.61528 - Nearby events: https://openairdocs.org/map.md?lat=38.4872&lon=-77.6153&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report May 30, 2006 - Report: Approved by Office Director - Parties: Textron Lycoming, FAA Dulles FSDO - NTSB case key (mKey): 60350 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC05FA006 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60350/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=60350 - Page: https://openairdocs.org/ntsb/NYC05FA006 ## Probable cause The pilot's inadequate preflight preparation, which resulted in an attempted takeoff with full flaps, and subsequent loss of control. ## 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 - flight control,flap - extended - preflight planning/preparation - inadequate, pilot in command (cause) - weather condition - gusts - aircraft control - not maintained, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The airplane had not been flown for about 5 years prior to the accident, and was undergoing maintenance in preparation of a ferry flight. A mechanic reported that he had asked the pilot to conduct some engine run-ups as close to full power as possible. The pilot taxied to runway 35, a 2,470 foot-long, 35 foot-wide, gravel and turf runway; where he performed two high speed engine run-ups. The mechanic thought that the pilot was going to perform another run-up, when the airplane accelerated, and lifted off the runway. He noted that it appeared that the pilot departed with full flaps, or at least "more than 10 degrees." The airplane began to climb momentarily, before it rolled left about 90 degrees and descended. The airplane's outboard left wing contacted the ground first, before the remainder of the airplane impacted in a nose down position, about 400 feet to the west of the departure end of the runway. Examination of the airplane did not reveal any mechanical malfunctions. Flap actuator measurements of the inboard and outboard, right and left flap actuator rods corresponded with a flap extension of 30 degrees. The airplane flight manual (AFM) procedure for "minimum run" and "obstacle takeoffs" was to utilize a 20-degree flap setting. With regards to conducting a go-around, with the flaps fully extended, the AFM stated to retract the flaps immediately to the 20-degree position. The AFM further indicated that most of the lift gained by lowering the flaps was found in the first 20 degrees of travel. The last 10 degrees provided some lift, but caused much drag..." The weather reported at an airport located about 10 miles southeast of the accident site, included clear skies, and winds from 230 degrees at 9 knots, with gusts to 19 knots. ## Factual narrative HISTORY OF FLIGHT On October 17, 2004, about 1400 eastern daylight time, a Beech H50, N171S, was destroyed when it impacted terrain during takeoff from the Hartwood Airport (8W8), Hartwood, Virginia. The certificated airline transport pilot was fatally injured. Visual meteorological conditions prevailed and no flight plan had been filed for the local maintenance test flight conducted under 14 CFR Part 91. The airplane was based at 8W8, and utilized in parachuting operations. The pilot flew the airplane on September 25, 1999, when it experienced a right engine failure, and landed at 8W8 without further incident. According to airport personnel, the airplane remained at the airport, where it was parked outside. The airplane was sold during July 2004, and about 3 weeks prior to the accident, the airplane's new owner sent a mechanic to 8W8, to prepare the airplane for a ferry flight to an airport near Houston, Texas. During a telephone interview, the mechanic stated that he performed maintenance on the airplane that included assembling and installing a replacement right engine, and replacing the spark plugs and oil in the left engine. He also added 140 gallons of fuel to the airplane. A 10 day ferry permit was obtained from the Federal Aviation Administration (FAA) on September 22, 2004; however, the airplane was not able to be flown because of a fuel pressure problem on the right engine. The mechanic returned home to Houston to research the problem, and then returned to 8W8 the day before the accident. The mechanic replaced an oil filter screen associated with the right engine supercharger fuel delivery system, which corrected the fuel pressure problem. He then taxied the airplane and conducted a series of engine run-ups. After the run-ups, the mechanic asked the accident pilot to conduct some engine run-ups as close to full power as possible. The pilot taxied to runway 35, a 2,470 foot-long, 35 foot-wide, gravel and turf runway; where he performed two high speed engine run-ups. The mechanic thought that the pilot was going to perform another run-up, when the airplane accelerated, and lifted off the runway. The airplane began to climb, "stalled", and impacted the ground. He also stated that it appeared that the pilot departed with full flaps, or at least "more than 10 degrees." The mechanic added that he had not completed inspecting the airplane and felt it was not ready for flight. He expected the airplane to be flown to Houston, the day after the accident, after the issuance of another ferry permit. Witnesses observed the airplane bank to the left, and turn about 180 degrees, before it impacted the ground in a nose down position, about 400 feet to the west of the departure end of runway 35. The airplane then bounced, and came to rest on a heading of about 50 degrees. The accident occurred during the hours of daylight approximately 38 degrees, 29.22 minutes north latitude, and 77 degrees, 36.91 minutes west longitude. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate for multi-engine land airplanes, and a commercial pilot certificate for single-engine land airplanes. Review of his logbook revealed he had accumulated approximately 5,905 hours of total flight experience, which included about 4,050 hours in multiengine airplanes. It was reported that the pilot had accumulated about 350 total hours in the accident airplane. The pilot had logged about 53 hours of total flight experience during the 90 days preceding the accident, which included about 14 and 39 hours in single and multiengine airplanes, respectively. The pilot's most recent Federal Aviation Administration (FAA) second class medical certificate was issued on February 14, 2004. AIRCRAFT INFORMATION According to maintenance records, the airplane's most recent annual inspection was performed on June 15, 1999. The left engine was overhauled on October 6, 1988, and had accumulated about 1,380 hours at the time of the annual inspection. The right engine was removed from another airplane on April 25, 1999, and had accumulated 1,012 hours since overhaul. METEOROLOGICAL INFORMATION The weather reported at an airport located about 10 miles southeast of the accident site, included clear skies, and winds from 230 degrees at 9 knots, with gusts to 19 knots. WRECKAGE AND IMPACT INFORMATION All major portions of the airplane were accounted for at the accident site. Except for the aft 10 feet of the empennage, the cockpit and cabin were consumed during a post crash fire. The outboard 14 feet of the right wing and the entire left wing remained intact except for fire damage at their inboard wing roots, and respective nacelle areas. The outboard 7 feet of the left wing was crushed aft to about a 45 degree angle, and was partially separated. Flight control continuity was confirmed from all primary control surfaces to the center of the cabin. Flap actuator measurements of the inboard and outboard, right and left flap actuator rods corresponded with a flap extension of 30 degrees. Both engines were severely fire damaged; however, the fire damage to the right engine was more extensive. All accessories from the right engine had separated and were consumed in the fire; some accessories remained attach to the left engine, however, they were also destroyed. The right engine could not be rotated. The left engine crankshaft could be rotated about 10 degrees, and continuity was observed to the accessory section. A borescope was utilized to examine the cylinders and crankcase for both engines, and there was no evidence of any catastrophic mechanical failures. Both propellers were located at the initial impact point, which was about 65 feet from the main wreckage. The propellers were located about 15 feet apart, and were partially buried in the ground. Both propeller assemblies separated at their attach points, which contained a torsional shear lip, of about 45 degrees. Each propeller contained three blades. All the left propeller blades contained chordwise scratches. One blade had rotated to near a feathered position, and was bent slightly opposite the direction of rotation. All right engine propeller blades also contained chordwise scratches, with one blade bent about 15 degrees. The main fuel valve screen was absent of contamination. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot, on October 18, 2004, by the Office of the Chief Medical Examiner, Fairfax, Virginia. The toxicological testing report from the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, was negative for drugs and alcohol for the pilot. ADDITIONAL INFORMATION Video A witness at the airport captured two engine run-ups and the accident flight on videotape. The witness stated that he had talked with the pilot earlier in the day, and the pilot told him that he was going to fly the airplane on a test flight. The airplane's flaps were observed in an extended position. During the accident flight, the airplane lifted off the runway, and began to climb momentarily, before it rolled left about 90 degrees and descended. The airplane's outboard left wing contacted the ground first, before the remainder of the airplane impacted in a nose down position. Airplane Flight Manual According to the airplane flight manual (AFM), the airplane was equipped with electrically operated wing flaps which were comprised of four sections, two on the center section, and one on the outer panel of each wing. The maximum flap extension was 30 degrees. For "minimum run" and "obstacle takeoffs" the flight manual outlined procedures for takeoffs with 20-degree flap settings. With regards to conducting a go-around, with the flaps fully extended, the AFM stated to retract the flaps immediately to the 20-degree position. The AFM further stated: "The reason for this is that most of the ## Aircraft - Registration: [N171S](https://openairdocs.org/deregistered/N171S-2011-06-08), registration cancelled 2011-06-08, S/N HH-125, built 1959 (OpenAirDocs) - Reported make and model: Beech H50 - Registry model: [Beech H50](https://openairdocs.org/model/beech-h50) (registry code 1152534) (OpenAirDocs) - Registry engine: [Lycoming GSO&IGSO-480 series](https://openairdocs.org/engine/lycoming-gso-igso-480-series) (registry code 41529, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: HH-125 - Airframe hours: 5150 - Engines: Lycoming IGSO-480 340 horsepower reciprocating; Lycoming IGSO-480 340 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Flight test, Part 91 - Registered owner: Scott Morgan - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 1, 1999 - Departed: 8W8, Hartwood, VA - Destination: 8W8, Hartwood, VA - Airport: 8W8, Hartwood, runway 35, 2,470 × 35 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: fatal; airline transport, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review August 1, 2004; seat: left; toxicology performed; flight hours: 5,904 total, 350 in this make and model, 5,055 as pilot in command, 53 in the last 90 days, 24 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 9 knots, gusting 19 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 59 °F, dew point 28 °F - Altimeter: 29.88 inHg - Observed at: RMN, 10 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 20041017031089A](https://openairdocs.org/incident/20041017031089A), Oct 17, 2004: Beech H50, Somerville, VA, Destroyed, 1 fatal. (-23) During takeoff, N171S experienced an apparent power problem. The airplane rolled left just off the end of runway 35 and descended at a 90 degree angle… ## Other investigations on N171S (1) 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. - [NTSB BFO91LA073](https://openairdocs.org/ntsb/BFO91LA073), Jul 14, 1991: Beech H50 (N171S), Hartwood, VA, substantial damage. Probable cause: THE PARACHUTIST FAILURE TO PROPERLY MONITOR AND SECURE HIS RELEASE HANDLE TO PROTECT AGAINST ACCIDENTAL PARACHUTE DEPLOYMENT. ## Docket (8 files) The files NTSB released with the investigation on March 20, 2006, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=60350. 8.3 MB in all. - Pilot Logbook (excerpt) (item 1, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40255410&FileExtension=.PDF&FileName=Pilot%20Logbook%20(excerpt)-Redacted.PDF - Ferry Permit and Bill of Sale (item 2, .PDF, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40256856&FileExtension=.PDF&FileName=Ferry%20Permit%20and%20Bill%20of%20Sale-Redacted.PDF - Maintenance Records (excerpts) (item 3, .PDF, 328 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40257204&FileExtension=.PDF&FileName=Maintenance%20Records%20(excerpts)-Redacted.PDF - Witness Memorandums (item 4, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40256775&FileExtension=.PDF&FileName=Witness%20Memorandums-Redacted.PDF - FAA Toxicology Report (item 5, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40256880&FileExtension=.PDF&FileName=FAA%20Toxicology%20Report-Redacted.PDF - Aerial View of Airport (item 6, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40255415&FileExtension=.PDF&FileName=Aerial%20View%20of%20Airport-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 7, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40256860&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Photograph # 1: Airplane as it came to rest. (item 8, .PDF, 855 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40255416&FileExtension=.PDF&FileName=Photograph%20%23%201%3A%20Airplane%20as%20it%20came%20to%20rest.-Master.PDF 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.