# NTSB WPR19LA223: Beech 35, N5410D, Ruidoso, NM, August 17, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: August 17, 2019, 12:55 local (18:55 UTC) - Place: Ruidoso, NM - Coordinates: 33.466667, -105.535 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.4667&lon=-105.5350&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: FAA - NTSB case key (mKey): 100076 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19LA223 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100076/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100076 - Page: https://openairdocs.org/ntsb/WPR19LA223 ## Probable cause The airplane’s inability to maintain altitude during the initial climb due to a degradation in the airplane’s performance as a result of high-density altitude conditions at the time of takeoff. Contributing to the accident were the pilot’s inadequate preflight performance planning calculations. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Aircraft capability: climb capability](https://openairdocs.org/ntsb-findings/01061010): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Beech H35, 1 case](https://openairdocs.org/ntsb-findings/01061010/cases.md?model=1151520), [All aircraft, 183 cases](https://openairdocs.org/ntsb-findings/01061010/cases.md) - [Temp/humidity/pressure: high density altitude](https://openairdocs.org/ntsb-findings/03031020): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Beech H35, 1 case](https://openairdocs.org/ntsb-findings/03031020/cases.md?model=1151520), [All aircraft, 278 cases](https://openairdocs.org/ntsb-findings/03031020/cases.md) - [Planning/preparation: performance calculations](https://openairdocs.org/ntsb-findings/02061010): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech H35, 1 case](https://openairdocs.org/ntsb-findings/02061010/cases.md?model=1151520), [All aircraft, 114 cases](https://openairdocs.org/ntsb-findings/02061010/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech H35, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1151520), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) (defining event); cases with it: [Beech H35, 3 cases](https://openairdocs.org/ntsb-events/490/sequence.md?model=1151520), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) ## Analysis The pilot and one passenger were departing from an airport located at an elevation of 6,813 ft mean sea level (msl). The pilot determined that, based on the temperature and gross weight of the airplane, the takeoff ground roll distance was about 2,900 ft total distance required to clear a 50-ft obstacle. The runway was 6,300 ft long. The pilot reported that the airplane became airborne about halfway down the runway and climbed to about 150 to 200 ft above ground level when he noticed a loss of engine power and the airplane began to descend. The pilot maneuvered the airplane for a forced landing and the airplane impacted terrain, resulting in substantial damage. A postaccident examination of the airplane revealed no mechanical malfunctions that would have precluded normal operation, and onboard video revealed that the engine continued to produce sufficient power throughout the flight. Before the accident flight, the pilot determined that, based on his calculation, the density altitude was 8,500 ft mean sea level (msl). Based on the weather conditions reported by the airport’s automated weather observation at the time of the accident, the density altitude was about 9,700 ft msl, which required a takeoff distance of about 3,300 ft. It is likely that the takeoff and climb performance, due to the density altitude, was degraded to an extent beyond that anticipated by the pilot, and the airplane was unable to maintain altitude. ## Factual narrative On August 17, 2019, about 1255 mountain daylight time, a Beechcraft H35 airplane, N5410D, was destroyed when it was involved in an accident near Ruidoso, New Mexico. The pilot and pilot-rated passenger were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, the day before the accident, he flew the airplane from Texas to the accident airport with no issues. He also added that he had flown in and out of the accident airport several times before and was familiar with high density altitude operations. Before the accident flight, the pilot determined that, based on his calculation, he reported that the density altitude was 8,500 ft mean sea level (msl), and the airplane’s weight was 2,803 pounds which was about 100 pounds under gross weight and within the center of gravity envelope. The takeoff ground roll distance required about 2,900 ft to clear a 50-ft obstacle. The runway was 6,300 ft long. The pilot leaned the engine for maximum performance and determined that if the airplane did not reach takeoff speed by the 3,000-foot runway marker, he would abort the takeoff. The airplane reached rotation speed about midfield and climbed to about 150 to 200 ft above ground level (agl) when the pilot noticed a loss of engine power. The airplane began to descend, and the pilot maneuvered the airplane for a forced landing. A witness located on the west side of the airport saw the accident airplane flying unusually low (no higher than 100 ft agl) in a northerly direction over runway 30. When it reached the intersection of runway 06/24, it started to descend out of view. The witness could hear the engine, and at no time did he see any smoke or vapors. He then ran to the terminal and prepared the fire truck and drove it to the accident site. Once there, he observed that about 5 gallons of fuel had leaked out of one of the wings, which had struck a tree. The airframe was severely damaged, and the engine was detached from the airframe. The left magneto was attached, and the right magneto mount was partially damaged. The starter was detached. The carburetor was severely damaged. All cylinders remained attached to the crankcase. The top spark plugs, and cylinder rocker box covers were removed. The top spark plugs were intact and exhibited normal operational signatures. The electrode gaps were consistent with service specifications. The crankshaft was rotated by hand and rotational continuity was established throughout the engine and valve train to the accessory section. Equal movement was observed on all the intake and exhaust valve rocker arms. Thumb compression and suction was obtained on all six cylinders. The magnetos were actuated by rotating the crankshaft, and spark was observed. The intake system was severely damaged, although it remained intact at the cylinder’s heads. The air filter and filter housing were severely damaged. The exhaust system was severely damaged, althoughit remained intact at the cylinder heads. The engine cylinders were examined internally using a lighted borescope. The piston tops and cylinder sidewalls appeared normal. No evidence of foreign object ingestion was observed. The examination revealed no mechanical malfunction that would have precluded normal operation. An onboard GoPro camera captured the accident takeoff in two video files; the first contained audio and video of the airplane taxiing to the runway and the second contained audio and video of the takeoff and subsequent impact with terrain. Both videos showed the instrument panel. The first video showed that the tachometer gauge read 1,300 rpm and an engine total time of 1,781.74 hours. The fuel pressure indicator read 3 psi, the manifold pressure indicator read 13 inHg, and the suction gauge read 4.75 inHg. The altimeter indicated an altitude of about 6,750 ft msl, and the fuel quantity gauge indicated 51.6 gallons of fuel remaining. The second video showed that the pilot applied power and the airplane began to accelerate down the runway. The tachometer indicated 2,600 rpm, the fuel pressure indicator read 6.5 psi, the manifold pressure indicator read 22.5 inHg, and the suction gauge read 6 inHg. About 40 seconds after the airplane started to accelerate, it lifted off the runway. The pilot retracted the landing gear, and about 25 seconds after takeoff, the intersecting runway, 6/24, was visible as it passed below. About 38 seconds after liftoff, the tachometer indicated 2,400 rpm, the manifold pressure indicator read 23 inHg, and the suction gauge indicated 5.8 inHg. The landing gear indicator showed that the gear was retracted, and the propeller control lever was in the full-forward position. About a half-second later, the camera revealed that the throttle lever was in the full forward position, the mixture control lever appeared to be in line with the throttle lever and in the full forward (rich) position, and the yoke was being pulled aft. The airplane impacted terrain 40 seconds after takeoff. Based on the weather conditions reported by the airport’s automated weather observation system at 1255, the density altitude at the time of the accident was about 9,700 ft msl, which required a takeoff distance of about 3,300 ft. ## Aircraft - Registration: [N5410D](https://openairdocs.org/deregistered/N5410D-2022-07-30), registration cancelled 2022-07-30, S/N D-4882, built 1956 (OpenAirDocs) - Reported make and model: Beech 35 (H35) - Registry model: [Beech H35](https://openairdocs.org/model/beech-h35) (registry code 1151520) (OpenAirDocs) - Registry engine: [Continental O-470 series](https://openairdocs.org/engine/continental-o-470-series) (registry code 17026, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-4882 - Year built: 1956 - Airframe hours: 3285 - Engines: Continental IO-470-G 240 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Michael Bletsch & Andrew Spiwak - Registered owner: Michael Bletsch & Andrew Spiwak - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 14, 2019 - Destination: BPG, Big Springs, TX - Flight plan: IFR - Airport: SRR, Sierra Blanca Rgnl, runway 030, 6,309 × 75 ft, concrete - Equipment: Satellite tracking device, Stall warning system, ADS-B, Electronic flight bag or handheld device, Handheld GPS, Onboard weather ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 37; injuries: serious; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review January 22, 2019; seat: left; restraint: 4-point; flight hours: 1,052 total, 10 in this make and model, 980 as pilot in command, 80 in the last 90 days, 24 in the last 30 days, 4 in the last 24 hours - Pilot-rated passenger; private; seat: left ## Weather - Conditions: Visual (VMC), Day - Wind: 340° at 12 knots, gusting 17 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 39 °F - Altimeter: 30.20 inHg - Observed at: KSRR, 1 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 20190817015659A](https://openairdocs.org/incident/20190817015659A), Aug 17, 2019: Beech H35, Ruidoso, NM, Destroyed. On August 17, 2019, at 1300 MST, a Beechcraft H35, N5410D, registered to [privacy data omitted], lost power shortly after takeoff and crashed into a ravine… ## Docket (8 files) The files NTSB released with the investigation on February 15, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100076. 16.3 MB in all. - Onboard image recorder - specialist's factual report (item 1, PDF, 12 pages, 15 photos, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13233069&FileExtension=pdf&FileName=factual_video_WPR19LA223_final_Redacted-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 2, PDF, 13 pages, 7.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12709615&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Pilot's performance planning calculations (item 3, PDF, 2 pages, 268 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13257351&FileExtension=pdf&FileName=N5410D%2081719%20performance%20planning-Rel.pdf - Witness statements (item 4, PDF, 1 page, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12709143&FileExtension=pdf&FileName=Witness%20statement-Rel.pdf - Engine exam (item 5, PDF, 1 page, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13236430&FileExtension=pdf&FileName=N5410D%20-%20Examination%20-%2025Feb2021%20--Rel.pdf - Last annual inspection (item 6, PDF, 3 pages, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12709449&FileExtension=pdf&FileName=Last%20inspection_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 7, PDF, 1 page, 681 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12709380&FileExtension=pdf&FileName=Wreckage%20release_Redacted-Rel.pdf - Photos (unknown source) (item 8, PDF, 2 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12709507&FileExtension=pdf&FileName=Photos%20(unknown%20source)-Rel.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.