WPR19FA252

NTSB accident investigation · Beech C24 · Las Vegas, NV · September 8, 2019

Accident · FatalClass 3 · FieldFinal report
Date
September 7, 2019, 19:50 local (Sep 8, 2019, 02:50 UTC)
Place
Las Vegas, NV
Injuries
2 fatal, 2 serious
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N24030Beech C24
Defining event
Initial climb: Loss of control in flight
Weather
Visual (VMC) · Dusk
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Textron Aviation, Lycoming Engines, FAA FSDO
FAA report
20190907014619A
Case key
100207

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

On this page

Probable cause

The pilot’s operation of the airplane over its maximum gross weight and outside of center of gravity limits at a high-density altitude, which resulted in the exceedance of the airplane's critical angle of attack while maneuvering and subsequent aerodynamic stall at low altitude. Contributing to the accident was the occupants’ failure to ensure the airplane’s doors were secure prior to takeoff.

Findings · 6

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Aircraft capability: maximum weightAircraft › Aircraft oper/perf/capability · Capability exceededBeech C24R: 1 caseAll aircraft: 152 casesProbable cause
Aircraft capability: maximum weightAircraft › Aircraft oper/perf/capability · Related operating infoBeech C24R: 1 caseAll aircraft: 152 casesProbable cause
Temp/humidity/pressure: high density altitudeEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentBeech C24R: 2 casesAll aircraft: 278 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech C24R: 1 caseAll aircraft: 990 casesProbable cause
Info processing/decision: decision making/judgmentPersonnel issues › Action/decision · Instructor/check pilotBeech C24R: 5 casesAll aircraft: 3,098 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotBeech C24R: 5 casesAll aircraft: 9,295 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot departed the runway and reported that a door had opened. After clearance to enter the traffic pattern and return to the airport, the airplane climbed to about 100 ft agl and struggled to gain altitude. The airplane turned left and subsequently entered a nose down left bank and impacted the terrain. The airplane sustained substantial damage. As the airplane banked to the left, it likely experienced an aerodynamic stall. Postaccident examination of the propeller blades revealed that the engine was likely operating near high rpm at impact, and examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The pilot’s operating handbook indicated an open door would slipstream and may result in buffeting and that the pilot is to fly the airplane “normally.” The occupants departed earlier the same day in the accident airplane and returned because the airplane was not being able to climb over mountains on their way to their destination. Density altitude was calculated to be 5,437 ft mean sea level at the airport. The airplane was also loaded over the maximum gross takeoff weight and exceeded the aft of the center of gravity limit for both flights. Although the airplane was able to take off, its overweight and aft of CG limit condition and the high-density altitude increased the airplane’s stall speed and degraded its climb performance, stability, and slow-flight characteristics. When the pilot turned the airplane left to return to the airport due to the reported open door, the critical angle of attack was likely exceeded and resulted in an aerodynamic stall at low altitude.

Factual narrative

According to the Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25B) Chapter 10, Weight and Balance, excessive weight reduces flight performance in almost every respect. Some of the most important performance deficiencies of an overloaded aircraft include higher takeoff speed, longer takeoff run, reduced rate and angle of climb, and higher stalling speed. According to the C24R Pilot’s Operating Handbook, the emergency procedure for an unlatched door in flight is as follows: If the cabin door latch is not fully engaged, it may come unlatched in flight. This usually occurs during or just after takeoff. The door will trail in a position approximately 3 inches open. A buffet may be encountered with the door open in flight. Return to the field in a normal manner. If practicable, during the landing flare-out have a passenger hold the door to prevent it from swinging open. On September 7, 2019, about 1950 Pacific daylight time, a Beechcraft C-24R, N24030, was destroyed when it was involved in an accident near Las Vegas, Nevada. The pilot receiving instruction and the flight instructor were seriously injured and the two passengers sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 cross-country instructional flight. Neither pilot provided a statement as to the events leading up to the accident. An eyewitness that was located at the north end of the Henderson Executive Airport (HND), Las Vegas, Nevada, was monitoring the tower frequency with a handheld radio. Additionally, he saw the accident airplane taxi near his location and perform a run-up, all while the airplane’s right entry door was open. The airplane’s engine sounded normal during the run-up and the entry door was then closed prior to the pilots receiving takeoff clearance and entering the runway. The eyewitness reported that the airplane appeared to roll down the runway of about 500-600 ft with about 50% power before full power was applied. Shortly after the airplane lifted off the runway. The airplane climbed to about 50 to 100 ft above ground level (agl) and struggled to gain altitude; climbing a few feet and then descending. The eyewitness heard the pilot’s report to the tower on his radio that a door had opened and his request to return to land. The airplane then appeared to climb an additional 50 to 100 ft agl then entered a left turn. Subsequently, the airplane entered a nose-down left bank and impacted the terrain. Air traffic control recordings revealed that the pilot taxied short of runway 17R and performed a runup prior to departure. The pilot reported that he was ready for departure and was then cleared for runway 17R. A few minutes later the pilot reported that a door opened during climb and that he needed to return. The pilot was cleared by the controller to enter right or left closed traffic. No more communication was heard from the pilot. Airport employees reported that the accident airplane arrived at HND around 0800 onthe day of the accident and parked at the transient parking for about 1-1/2 hours. The airplane was refueled to a little more than halfway up the fuel tank tabs. A total of 23 gallons of fuel was added to the airplane. Shortly after refueling, four individuals were aboard the airplane when it departed HND and then returned about a 30 minutes later to the transient parking area. An occupant on that flight stated to one of the airport employees that it was too hot, and that the airplane couldn’t climb to get around the mountains. At 1056, HND reported wind was variable at 3 knots, 10 miles visibility, clear skies, temperature at 36°C, dew point 11°C, and an altimeter setting of 29.98 inches of mercury. Later that evening at 1956, HND reported wind from 210° at 12 kts, 10 miles visibility, clear skies, temperature 34°C, dew point 4°C, and an altimeter setting of 29.80 inches of mercury. Density altitude was calculated to be about 5,437 ft msl. The airplane’s estimated total weight at the time of the accident, including about 40 gallons of fuel, four occupant weights and the weight of tools was about 2,835 lbs. The airplane’s takeoff distance was calculated using a performance chart from the airplane’s Pilot’s Operating Handbook. According to the chart, at the airplane’s maximum gross weight of 2,750 lbs, temperature of 34°C, at a pressure altitude of 5,437 ft mean sea level (msl), with a cross wind component of 6 knots, the airplane required a ground roll distance of 1,900 ft and 2,800 ft to clear a 50 ft obstacle. The airplane's maximum rate of climb at maximum gross weight would have been about 525 ft per minute (fpm). The airplane was loaded over the max gross takeoff weight and aft of the center of gravity moment envelope for both flights. Examination of the accident site revealed that the airplane impacted a divided roadway, slid through a steel barrier fence, and came to rest in a culvert drainage area. The empennage separated from the main wreckage just aft of the baggage door area and was found adjacent to the culvert entrance. The main wreckage was partially consumed by post-impact fire. The cabin area and the wing’s inboard sections, including the wing fuel tanks were mostly consumed by post-impact fire. Both entry doors and the baggage door were mostly consumed by post-impact fire. The latch assemblies for all doors were identified and were in the engaged (out) position. The aft baggage door latch strike plate was found and showed normal signs of wear. The latch strike plates for the two entry doors were not found during the examination of the wreckage. The postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation.

Aircraft

Registration
N24030
Reported as
Beech C24 (R)
Category
Airplane
Serial number
MC-487
Built
1977
Airframe hours
4,744
Engine
Lycoming IO-360-A1B6, 200 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Instructional · Part 91
Operator
California Flight Academy
Registered owner
So Cal Leasing LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 21, 2019
Departed
HND · Las Vegas, NV
Destination
SEE · El Cajon, CA
Flight plan
VFR
Airport
HND · Henderson Executive, runway 17R, 6,501 × 100 ft, asphalt
Equipment
ADS-B, Stall warning system

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
26
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 1, Without waivers/limitations
Last flight review
April 25, 2019
Seat
Left
Role
Flight instructor
Age
31
Injuries
Serious
Certificate
Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
May 22, 2019
Seat
Right
Flight hours
250 total · 200 as pilot in command

Weather

Conditions
Visual (VMC) · Dusk
Wind
210° at 12 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
93 °F, dew point 39 °F
Altimeter
29.80 inHg
Observed at
KHND
METAR
METAR KHND 080256Z 21012KT 10SM CLR 34/04 A2980 RMK AO2 SLP073 T03440044 55000

Docket · 15

The files NTSB released with the investigation on April 6, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 23.6 MB in all.

FAA reports on this event · 1

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