SEA04FA188

NTSB accident investigation · Beech A-36 · Auburn, WA · September 13, 2004

Accident · Serious injuriesField investigationFinal report
Date
September 12, 2004, 18:10 local (Sep 13, 2004, 01:10 UTC)
Place
Auburn, WA
Injuries
3 serious, 1 minor
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
N100EVBeech A-36
Weather
Visual (VMC) · Day
Status
Completed · report October 27, 2005
Report
Approved by Office Director
Parties
Seattle FSDO
FAA report
20040913035359A
Case key
60120

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's failure to abort the takeoff early enough to allow him to stop the aircraft before it went off the departure end of the runway. Factors include the pilot's inadequate preflight procedures, water contamination in the fuel, a partial loss of power, and a utility trailer parked off the departure end of the runway.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(partial) - nonmechanicalTakeoff - aborted
Fluid - contamination,water
Aborted takeoff - delayedPilot in commandCause
Preflight planning/preparation - inadequatePilot in commandFactor
On ground/water collision with objectTakeoff - aborted
Object - vehicleFactor

Analysis

On the day after the aircraft sat out all night, in what was at times heavy rain, the pilot performed a preflight inspection prior to his departure for a local sightseeing flight. During that preflight he collected fuel from the left wing tank, and that sample revealed about one inch of water in the bottom of the nine inch long fuel sampler. He also found trace amounts of water in the right tank and center drain sump. Although he took a second sample from the left tank that did not show any more water contamination, he did not rock the wings to dislodge any trapped water prior to taking the second sample. Then after starting the engine, he taxied on the uneven undulating grass surface in order to get to the north end of the grass runway. During that taxi, the aircraft's wings rocked gently dislodging additional trapped water. The pilot then initiated his takeoff to the south, and although the aircraft initially accelerated as expected, about one-quarter way down the runway, the engine experienced a partial loss of power. At that point the pilot lowered the aircraft nose, but elected to continue the takeoff roll. After a few seconds the engine accelerated to near full power, and the pilot increased the pitch attitude in an attempt to get the aircraft to climb. But before the aircraft had traveled two-thirds of the way down the runway, the engine starting coughing and missing again, and the pilot aborted the takeoff at or very near the end of the runway. Because he had delayed the abort, he was unable to stop the aircraft prior to it departing the end of the runway, crossing over a paved road, going through a barbed wire fence, and impacting some brush and a parked utility trailer. A post-accident engine inspection and engine run found no evidence of any mechanical failure or malfunction.

Factual narrative

History of flight

On September 12, 2004, approximately 1810 Pacific daylight time, a Beech A-36, N100EV, impacted a stand of dense brush and an enclosed equipment hauling trailer during an aborted takeoff at Evergreen Skyranch, Auburn, Washington. The commercial pilot and two of his passenger received serious burn injuries, and the third passenger received minor injuries. The aircraft, which was owned and operated by the pilot, was destroyed by the post-impact fire. The local 14 CFR Part 91 personal pleasure flight was being operated in visual meteorological conditions. No flight plan had been filed. The ELT, which was activated by the impact sequence, was turned off at the scene.

On the day of the accident, the pilot was entertaining guests at his home at Evergreen Skyranch. Around 1730 he invited the guests to accompany him on a sightseeing flight around the local area. Shortly thereafter, the pilot performed a normal preflight on the aircraft, which had been sitting overnight on the taxiway area in front of his house. He said that he took special care to check for water in the fuel samples because the aircraft had been sitting out overnight, in what was at times heavy rain. The preflight turned up no system anomalies, but the pilot did find that when he drained the left tank the fuel sample did yield about one inch of water in the nine inch long fuel sampler. In addition, the sample taken from the right tank and the fuel strainer sump revealed traces of water. Prior to starting the engine, the pilot took a second sample of fuel from the left tank, and that sample did not contain any further water contamination. In a post-accident interview, when asked if he had rocked the wings of the aircraft in an attempt to dislodge any additional trapped water, he said that he had not. He further stated that in the time that he had owned the aircraft, approximately one month, this was the first time that he had seen anything besides a very small trace amount of water in a fuel sample.

The pilot then loaded his passengers and provided them with some emergency instructions. He and an adult male passenger were in the front two seats, and two relatively light young adults were seated in the two most aft seats. After confirming that there were approximately 65 gallons of fuel on board, the pilot started the engine and let it warm up with the aircraft still parked on the taxiway pad where it had been overnight. After the engine had warmed sufficiently, the pilot performed a magneto and propeller check, both of which indicated normal operation. Then, just before the pilot was getting ready to start his taxi to the runway, a friend of his, who was inbound to Evergreen Skyranch at that time, transmitted over the common traffic advisory frequency (CTAF) that he was entering the traffic pattern for landing. At that point, because he believed his friend was arriving in order to visit with him, the pilot of N100EV decided to shut down the aircraft's engine and delay his takeoff until his friend had landed and taxied to his house. After the other pilot landed, the pilot of N100EV and the other pilot carried on a brief conversation over the radio, whereupon the pilot of N100EV decided to go ahead with the short sightseeing flight, and to join the guests afterward. He therefore restarted the engine, checked and set the instruments, and then initiated his taxi to the north end of the runway over the uneven undulating grass taxi area. Once he was clear of the area in front of his house, where other individuals where watching the activities, he performed another propeller and magneto check, and completed his pre-takeoff checklist, intentionally leaving the flaps in the full up position. Once he reached the north end of the runway, the pilot turned the aircraft to the south (runway 16) and initiated the takeoff roll.

In his written statement, the pilot said that during the take off roll, the aircraft accelerated normally up to the point of rotation. He said that it felt like the aircraft then lifted off the ground, but could not sustain a climb at the normal rotation and liftoff angle. He said that he therefore lowered the nose of the aircraft in an attempt to gain more airspeed, which according to the pilot, "...resulted in the sensation of a momentary surge of power." But, since he felt that the aircraft was just barely above the ground, and he didn't want the nose gear to contact the runway surface, the pilot increased the pitch angle "...in order to get a little more altitude to safely accelerate to best climb speed." But, since the aircraft did not climb, the pilot lowered the nose, and then decided to put the aircraft back on the ground and abort the takeoff. He stated that he landed on the last third of the runway, and then aimed toward a private taxiway in an area off the south end of the runway. As he turned toward the taxiway, he noticed that there where some people in front of a hangar near the taxiway, so he turned to the right, away from those individuals, and toward an area near where there was some thick brush and an enclosed utility trailer. His statement said that he thought he could absorb the airplanes energy by hitting the trailer and bouncing the trailer forward.

In a post-accident person-to-person interview with the Investigator-In-Charge (IIC), the pilot stated that although he was not sure, he thought the aircraft may have been as high as 20 feet in the air when it was almost half way down the runway, but that the engine then began to cough and miss. That made him think that he was experiencing induction icing, so he lowered the nose, hoping that the expected acceleration might help the problem. He stated that at that point the engine accelerated and seemed to be at full power, so he thought everything was going to be fine if he continued the takeoff. But, a few seconds later, when he was about two-thirds of the way down the runway, the engine started coughing and dieing out again. He said that he then decided to abort the takeoff, and seeing that he was not going to be able to stop by the end of the runway surface, he headed toward an open area off the south end of the runway where there was a trailer that he believed was empty. According to witnesses, the aircraft impacted the trailer and some brush at about the same time, and then a large ball of flame immediately engulfed the trailer and the front of the aircraft. Immediately thereafter the back seat passengers exited the aft door, and after a momentary problem with the right seat passenger not knowing how to open the over-wing passenger door, the two individuals in the front seat exited the aircraft.

As part of the investigative process, the Investigator-in-Charge interviewed or took written statements from a number of witnesses. The three witnesses that were the closest to the aircraft during the initial part of the takeoff sequence were the pilot's wife, the friend who had flown in just prior to the pilot taxiing out for departure, and another pilot who lives across the runway and about 500 feet further north. All three of these witnesses where adamant in stating that the aircraft's main wheels did not lift off from the grass runway from the time it started its takeoff roll until it went out of their direct line of sight to the south (a little over half way down the runway). The pilot's friend stated that he could not fully see the aircraft's undercarriage during the first few hundred feet of the takeoff roll, but that when it became fully visible he could see that the nose wheel was off the ground, and the aircraft was at a higher than normal pitch attitude for a takeoff roll. He said that as the aircraft continued the takeoff roll, the nose wheel was high in the air, but the aircraft appeared to be going too slow to lift off. He said that as the aircraft neared his position, the nose wheel dropped suddenly and rapidly to the ground, but only stayed there for two or three sec

Aircraft

Registration
N100EV
Reported as
Beech A-36
Category
Airplane
Serial number
E2834
Airframe hours
1,337
Engine
Continental IO-550-B, 300 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Michael C. Muma
Registered owner
Eagle River Aviation, LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 1, 2003 · 51 hours before
Departed
51WA · Auburn, WA
Destination
51WA · Auburn, WA
Airport
51WA · Evergreen Skyranch, runway 16, 2,600 × 75 ft, grass/turf

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
63
Injuries
Serious
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Medical
Class 2, With waivers/limitations
Last flight review
August 1, 2004
Seat
Left
Flight hours
1,300 total · 18 in this make and model · 18 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
240° at 5 knots
Visibility
20 statute miles
Lowest ceiling
10,000 ft overcast
Temperature
61 °F

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.