# NTSB WPR20LA289: Beech A36, N1550G, Redding, CA, August 27, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: August 27, 2020, 06:30 local (13:30 UTC) - Place: Redding, CA - Coordinates: 40.573612, -122.407218 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.5736&lon=-122.4072&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300) - Highest injury: Fatal - Injuries: 2 fatal, 2 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Textron Aviation, Federal Aviation Administration - NTSB case key (mKey): 101871 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR20LA289 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101871/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101871 - Page: https://openairdocs.org/ntsb/WPR20LA289 ## Probable cause The pilot’s failure to recognize the airplane’s inadequate takeoff performance given the length of the available runway and to abort the takeoff, which resulted in a runway excursion. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech A36, 27 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1151604), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Aircraft capability: takeoff distance](https://openairdocs.org/ntsb-findings/01061025): Aircraft › Aircraft oper/perf/capability · Not specified (probable cause); cases with it: [Beech A36, 1 case](https://openairdocs.org/ntsb-findings/01061025/cases.md?model=1151604), [All aircraft, 67 cases](https://openairdocs.org/ntsb-findings/01061025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Beech A36, 20 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=1151604), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech A36, 78 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151604), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot and three passengers were departing from a 2,420-ft-long runway when the accident occurred. A witness reported that the airplane appeared to be accelerating slowly, and that it suddenly rotated and appeared to lift off slightly before settling back to the ground, which caused the nosewheel to come back down to the runway surface. The airplane rotated abruptly a second time and remained in a nose-high attitude while approaching the departure end of the runway. The witness estimated the airplane’s speed as about 60 to 65 knots as it passed his location in a nose-high attitude. The witness added that, throughout the takeoff roll, the “engine sounded like it was producing full power and the propeller was producing full rpm.” Review of security camera recordings revealed that the airplane appeared to rotate about 700 ft from the departure end of the runway and remain in a nose-high attitude. The airplane briefly became airborne about 300 ft from the departure end of the runway and remained in a nose-high attitude before it settled back onto the runway surface about 2 seconds later and continued off the departure end of the runway: a post-impact fire ensued. Postaccident examination of the airplane revealed no evidence of any preexisting mechanical malfunction that would have precluded normal operation. A review of weight and balance information indicated that the airplane was about 23 lbs under its maximum gross weight at the time of the accident. Depending on the passenger seating configuration, which could not be determined, the airplane could have been within its center of gravity (CG) limitations or up to about 2 inches forward or about 1.75 inches aft of the CG envelope limit. Calculated takeoff performance for an airplane within the CG envelope given the atmospheric conditions and gross weight at the time of the accident showed that the airplane would have required 1,978 ft for a no-flap takeoff with no obstacle, or 3,558 ft for a no-flap takeoff to clear a 50-ft obstacle if takeoff power was applied prior to brake release. The extent of the pilot’s preflight takeoff performance planning and his takeoff technique could not be determined based on the available information. The circumstances of the accident are consistent with the pilot’s failure to recognize the airplane’s inadequate takeoff performance given the length of the available runway and his subsequent failure to abort the takeoff, which resulted in a runway excursion. ## Factual narrative The airplane was equipped with six seats; two forward, two middle rear-facing seats, and two forward-facing aft seats. The airplane was equipped with a Whirlwind III turbonormalizing system as part of supplemental type certificate (STC) SA5222NM. The STC also included a maximum gross weight increase from 3,560 lbs to 4,000 lbs. The performance section of the airplane flight manual supplement for the STC stated that it was “not FAA approved;” however, when operating at the increased weights, the pilot should expect an increased takeoff distance of up to 30 percent. The supplement further stated that takeoff speeds were to be increased by 2 knots. The takeoff performance chart stated that, at 3,650 lbs, the takeoff rotation speed would be 73 knots. Utilizing the airplane’s weight and balance record and the weights of the four occupants, 54 gallons of fuel, and no baggage, weight and balance values were calculated for the accident flight. The airplane’s gross weight was estimated to be about 3,977 lbs. The rear passengers’ seating positions could not be determined nor could the positions of the forward and middle aft facing seats. The center of gravity (CG) was calculated using the passenger and seat locations in the most favorable position and was found to be within CG limitations in three of seven passenger and seat position configurations. Dependent on the seating positions of the rear passengers, the CG ranged varied from about 2 inches forward of the forward limit, to about 1.75 inches outside of the rear limit of the CG envelope. Given the atmospheric conditions at the time of the accident, the airplane’s gross weight, and presuming that its CG was within limits during the accident takeoff, the airplane would have required 1,978 ft for takeoff with flaps retracted, or 3,558 ft to clear a 50-ft obstacle. This calculated distance includes the 30% increase in takeoff distance when operating at the increased maximum gross weight allowed by the STC. On August 27, 2020, about 0630 Pacific daylight time, a Beech A36 airplane, N1550G, was destroyed when it was involved in an accident near Redding, California. The pilot and three passengers sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations 91 personal flight. A witness, who was a rated pilot and a law enforcement officer, reported that while at his desk, which overlooked the runway, he heard the noise of an airplane engine increase as it started its takeoff roll from runway 33. He saw the accident airplane come into view on runway 33; however, it “wasn’t accelerating at a normal rate for that type of aircraft.” The airplane continued the takeoff roll, accelerating much more slowly than he was accustomed to seeing; it rotated abruptly, “to a slightly steeper angle of attack than a normal takeoff and it appeared to lift off slightly before settling back to the ground; which caused the nosewheel to come back down to the runway surface.” The witness furtherstated that, as the airplane continued the takeoff roll, it [the airplane] again rotated abruptly and remained in a nose-high attitude while approaching the departure end of runway 33. As the airplane passed directly in front of the witness’s location, the airplane was in a nose-high attitude, at a speed of about 60 to 65 knots. The witness added that, throughout the takeoff roll, the “engine sounded like it was producing full power and the propeller was producing full rpm.” Two security cameras located near the witness’s location captured the accident airplane’s takeoff sequence (locations outlined in figure 1). Camera 1 initially captured the accident airplane during takeoff roll about 1,500 ft from the departure end of runway 33 at a camera time of 0643:31. The airplane continued its takeoff roll, and at 0643:39, the nose wheel appeared to lift off the runway surface, consistent with rotation, about 700 ft from the departure end of runway 33. (see figure 2.) The airplane continued in a nose-high attitude with the main landing gear remaining on the runway surface until the airplane traveled out of view of the camera frame at 0643:41. Camera 2 captured the airplane traveling into view at 0643:39 in a nose-high attitude, with the main landing gear remaining on the ground. The airplane appeared to briefly become airborne at 0643:42, while remaining in a nose-high attitude, about 310 ft from the departure end of the runway and settled back onto the runway surface 2 seconds later. The airplane exited the departure end of the runway and traveled down an embankment out of view of the camera. A ball of fire could be seen erupting from the tree line north of the runway. The witness provided a time versus distance calculation based on measurements between two points of the runway. He estimated the approximate speed of the airplane as it was passing the runway 15 visual approach slope indicator to be about 70.9 miles per hour, or 61.6 knots. Figure 1. Google Earth plot of camera locations, approximate rotation area, and runway distance remaining Figure 2. Camera 1 view of the accident airplane rotation The calculated density altitude at the time of the accident was 1,607 ft. Review of the pilot’s logbook revealed 463.3 total hours of flight experience. The pilot recorded a total of 38.3 hours in the accident airplane, of which 10.8 hours were without a flight instructor. Previous flight experience in the available logbooks was in a Cessna 150. The right seat passenger held a flight instructor certificate. Review of his logbook revealed 339 hours of total flight experience. He did not have any recorded flight experience in the accident airplane make and model. The airplane came to rest down an embankment and was mostly consumed by fire. All major structural components of the airplane were located within the vicinity of the main wreckage. Remains of the firewall, cockpit instrumentation, gearbox, seat structures, and control yoke were identified within therecovered debris. The fuel selector valve was in the right fuel tank position, and the fuel strainer was melted. The left flap actuator drive cable was separated from the flap actuator motor, and the actuator measured 1.5 inches, consistent with the flaps in the retracted position. The right flap actuator was separated from the wing and measured at 2.1 inches, which equated to the flap being extended between 0 and 5°. Flight control continuity was partially established throughout. Both aileron direct cables remained attached to the bellcrank and separated in tensile overload at the inboard ends. The carrythrough cables on both wings were fractured at the bellcranks. Elevator control continuity was not established due to impact and thermal damage. Both rudder control cables remained attached to the bellcrank and visible ends appeared cut consistent with recovery operations. Examination of the airframe and engine revealed no evidence of any preexisting mechanical malfunction that would have precluded normal operation. ## Aircraft - Registration: [N1550G](https://openairdocs.org/aircraft/N1550G), registered now, S/N E-2484, built 1989 (OpenAirDocs) - Reported make and model: Beech A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-2484 - Year built: 1989 - Engines: Continental Motors IO-550-B reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Utility; Standard, Normal - Departed: O85, Redding, CA - Destination: PLU, Puyallup, WA - Airport: O85, Benton Field, runway 33, 2,420 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 463 total, 38.3 in this make and model - Flight instructor; injuries: fatal; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; seat: right; toxicology performed; flight hours: 339 total, 0 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 4 statute miles - Lowest ceiling: 3,200 ft overcast - Temperature: 68 °F, dew point 59 °F - Altimeter: 29.79 inHg - Observed at: KRDD, 6 nm away - METAR: METAR KRDD 271353Z AUTO 00000KT 4SM HZ OVC032 20/15 A2979 RMK AO2 SLP082 T02000150= ## 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 20200827012249A](https://openairdocs.org/incident/20200827012249A), Aug 27, 2020: Beech A36, Redding, CA, Destroyed, 4 fatal. On August 27, 2020, about 0645 pacific daylight time, a Beechcraft bonanza A36, N1550G, was destroyed moments after a failed attempt to takeoff from Benton… ## Docket (21 files) The files NTSB released with the investigation on November 2, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101871. 22.4 MB in all. - Witness statement (item 1, PDF, 5 pages, 326 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14561963&FileExtension=pdf&FileName=witness%20statement_Redacted-Rel.pdf - Refueler statement (item 2, PDF, 1 page, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14561838&FileExtension=pdf&FileName=Refueler%20Statement_Redacted-Rel.pdf - Fuel receipt (item 3, PDF, 1 page, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14561973&FileExtension=pdf&FileName=P66Receipt%20Garret%20N1550G_Redacted-Rel.pdf - NTSB airframe and engine examination summary (item 4, PDF, 4 pages, 200 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14678482&FileExtension=pdf&FileName=Airframe%20and%20Engine%20Exam%20Summary-Rel.pdf - NTSB video summary report (item 5, PDF, 5 pages, 6 photos, 956 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14678736&FileExtension=pdf&FileName=video%20review%20summary-Rel.pdf - Reports from parties to the investigation - Textron (item 6, PDF, 9 pages, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14561983&FileExtension=pdf&FileName=textron%20tech%20report%20Redacted-Rel.pdf - Pilot operating handbook section 5 performance (item 7, PDF, 40 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14562258&FileExtension=pdf&FileName=POH%20Section%205%20Performance-Rel.pdf - Pilot operating handbook section 6 weight and balance (item 8, PDF, 20 pages, 291 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14560971&FileExtension=pdf&FileName=POH%20Section%206%20%20Weight%20and%20Balance-Rel.pdf - General aviation modifications inc. correspondence (item 9, PDF, 3 pages, 686 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14562148&FileExtension=pdf&FileName=GAMI%20Correspondance_Redacted-Rel.pdf - Tornado alley turbo airplane flight manual supplement - performance section (item 10, PDF, 2 pages, 158 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14561647&FileExtension=pdf&FileName=tornado%20alley%20AFMS%20550%20Rev%20K%20Performance%20Section%205_Redacted-Rel.pdf - Maintenance workorder and weight and balance (item 11, PDF, 2 pages, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14562302&FileExtension=pdf&FileName=shop%20workorder%20and%20w%20and%20b%20info_Redacted-Rel.pdf - For sale advertisement for the accident airplane (item 12, PDF, 4 pages, 254 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14561565&FileExtension=pdf&FileName=sales%20brochure_Redacted-Rel.pdf - NTSB weight and balance and performance report (item 13, PDF, 5 pages, 338 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14591718&FileExtension=pdf&FileName=weight%20and%20balance%20and%20performance%20report-Rel.pdf - Weight and balance and performance report attachment (item 14, PDF, 2 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14562418&FileExtension=pdf&FileName=w%20an%20b%20performance%20attachment-Rel.pdf - Autopsy memo (item 15, PDF, 1 page, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14561774&FileExtension=pdf&FileName=Autopsy%20Memo-Rel.pdf - Statement of party representatives to NTSB investigation - Textron (item 16, PDF, 9 pages, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14561667&FileExtension=pdf&FileName=party%20form%20textron_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 17, PDF, 1 page, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14562003&FileExtension=pdf&FileName=WRECKAGE%20RELEASE%20SIGNED_Redacted-Rel.pdf - Toxicological report - pilot (item 18, PDF, 1 page, 341 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14656362&FileExtension=pdf&FileName=tox_Redacted-Rel.pdf - Photo array (item 19, PDF, 5 pages, 5 photos, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14561677&FileExtension=pdf&FileName=Photo%201-Rel.pdf - Camera 1 video (item 20, MP4, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14561617&FileExtension=mp4&FileName=Camera%201%20Video-Rel.mp4 - Camera 2 video (item 21, MP4, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14561555&FileExtension=mp4&FileName=Camera%202%20Video-Rel.mp4 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.