# NTSB WPR21FA353: Beech S35, N354M, Billings, MT, September 27, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: September 26, 2021, 19:22 local (Sep 27, 2021, 01:22 UTC) - Place: Billings, MT · On 63MT, a private airport - Coordinates: 45.715875, -108.57725 - Nearby events: https://openairdocs.org/map.md?lat=45.7159&lon=-108.5773&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-aborted after touchdown: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) - Highest injury: Fatal - Injuries: 2 fatal, 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: FAA, Textron Aviation - NTSB case key (mKey): 103962 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR21FA353 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103962/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103962 - Page: https://openairdocs.org/ntsb/WPR21FA353 ## Probable cause The pilot’s improper flare, which led to a hard landing, subsequent loss of control, and collision with trees. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: landing flare](https://openairdocs.org/ntsb-findings/01062041): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation; cases with it: [Beech S35, 1 case](https://openairdocs.org/ntsb-findings/01062041/cases.md?model=1151532), [All aircraft, 1,285 cases](https://openairdocs.org/ntsb-findings/01062041/cases.md) - [Performance/control parameters: lateral/bank control](https://openairdocs.org/ntsb-findings/01062023): Aircraft › Aircraft oper/perf/capability · Not attained/maintained; cases with it: [Beech S35, 2 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md?model=1151532), [All aircraft, 390 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot; cases with it: [Beech S35, 4 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1151532), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-flare/touchdown: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [Beech S35, 1 case](https://openairdocs.org/ntsb-events/090/sequence.md?model=1151532), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) - [Landing: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Beech S35, 2 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=1151532), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing-aborted after touchdown: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) (defining event); cases with it: [Beech S35, 10 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151532), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that he was conducting a cross-country flight with an intended destination that did not have runway lighting. As the airplane neared the intended destination, the pilot voiced his concern to one passenger (who was pilot rated) about the dusk conditions with no runway lights and the passenger reassured him about the landing. The pilot stated that, as the airplane was landing, the pilot-rated passenger knew something was wrong and told the pilot to “add power.” The airplane subsequently made a left turn and impacted trees in a nose-high attitude; a postimpact fire ensued. Witnesses located near the accident site reported observing the airplane on final approach. One witness stated that the airplane appeared to be “slightly high and slightly fast” while on final approach to the runway and that the airplane had “floated down the runway” before a hard touchdown. Another witness stated that the left wing appeared to have stalled, and that the airplane landed hard on the left main landing gear first. One of the witnesses further stated that the airplane began to “wobble” and depart the left side of the runway, which followed by an increase in engine power and a go-around attempt. The witness added that engine power continued as the left wingtip was dragged across the ground about halfway through the go-around attempt. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Based on the runway and ground marks, and witnesses’ observations of the landing, the pilot continued an unstabilized landing approach, and delayed execution of a go-around, which resulted in a hard landing and subsequent loss of airplane control. ## Factual narrative The airplane was equipped with a single control yoke. The left side was equipped with rudder pedals and brakes, and the right side was equipped with rudder pedals only. The runway at the private airport was oriented on an east-west heading. The runway was about 4,696 ft in length, of which, the western 3,100 ft of the runway surface was asphalt. The remaining runway surface was comprised of dirt and gravel. The runway was not equipped with runway lights or approach angle indicating equipment. Most of the length of the runway was surrounded by open fields. On September 26, 2021, about 1922 mountain daylight time, a Beech S35 airplane, N354M, was destroyed when it was involved in an accident near Billings, Montana. The pilot was seriously injured, and the two passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he was conducting a cross-country flight from Colorado to a private airstrip in Montana. As the airplane neared the intended destination, the pilot voiced his concern to one passenger (who was pilot rated) about the dusk conditions with no runway lights at the airstrip, and the passenger reassured the pilot about the landing. As the airplane entered the airport traffic pattern, the pilot was feeling “okay” and conducted the checklist. The pilot stated that, as the airplane was landing, one passenger knew something was wrong and told the pilot to “add power.” Subsequently, the airplane turned left and impacted trees, and a postimpact fire ensued. The pilot reported that he did not know what happened when the airplane touched down or why the airplane turned toward the trees. Regarding the airplane’s left turn after landing, the pilot “chalk[ed] it up to floating the landing somehow” and stated that everything was normal until the airplane turned left. He added that “something made the left wing hit the ground first, instead of the wheels.” Witnesses located near the accident site reported observing the airplane on final approach for the runway from the northeast. One witness stated that the airplane appeared to be “slightly high and slightly fast” while on final and that the airplane had “floated down the runway” before a “hard” touchdown. Another witness stated that the left wing appeared to have stalled and that the airplane landed hard on the left main landing gear first. A witness further stated that the airplane began to “wobble” and then depart the left side of the runway, which was followed by the sound of an increase in engine power. This witness stated that the airplane accelerated through a field in a nose-high attitude while doing what he described as a “duck waddle.” The witness indicated that engine power remained on as the left wingtip was dragged across the ground about halfway through an attempted go-around. The airplane came to rest within a tree line that was about 450 ft north of the runway and about 1,938 ft northeast of theapproach end the runway. All major structural components of the airplane were located within about 40 ft of the main wreckage. Examination of the runway revealed that the first identified point of contact was a tire mark, consistent with the left main landing gear, about 882 ft from the approach end of the runway. An additional mark, consistent with the right main landing gear, was located about 924 ft from the approach end of the runway. A solid black track, consistent with main tire material transfer, originated from both marks and progressed toward the left side of the runway. The tracks exited the runway surface about 1,078 ft from the approach end of the runway, as shown in figure 1. Figure 1.: Runway marks. A ground scar, consistent with the left wing, was about 60 ft in length and was located about 1,500 ft from the approach end of the runway and 91 ft left of the runway edge. Additional ground scars, consistent with the main landing gear, were observed about 68 ft beyond the left wing ground scar and in an arc toward the north and main wreckage, as shown in figure 2. Figure 3. Aerial view of the accident site, with ground scars and runway marks annotated. (Source: Witness to the accident). The fuselage was significantly damaged by the postimpact fire from the firewall to just behind the baggage area. Flight control continuity was established from the ailerons to the control column. Elevator control continuity was established from the forward spar to the control surfaces. Examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation of the airplane. ## Aircraft - Registration: [N354M](https://openairdocs.org/aircraft/N354M), registered now, S/N D-7516, built 1964 (OpenAirDocs) - Reported make and model: BEECH S35 - Registry model: [Beech S35](https://openairdocs.org/model/beech-s35) (registry code 1151532) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-7516 - Year built: 1964 - Airframe hours: 4408.4 - Engines: CONT MOTOR IO-520-BB3 285 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Mission Aviation - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 1, 2021 - Destination: Same as departure - Airport: 63MT, Billings Flying Service, runway E/W, 4,696 × 25 ft, dirt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 25; injuries: serious; flight instructor, private, commercial; airplane ratings: single-engine land, single-engine sea; instrument ratings: airplane; medical: class 1, with waivers/limitations; seat: left; flight hours: 373 total - Pilot-rated passenger; age 56; injuries: fatal; commercial, airline transport; airplane ratings: single-engine land, multi-engine land, single-engine sea; seat: right; flight hours: 25,000 total ## Weather - Conditions: Visual (VMC), Dusk - Wind: 140° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 23 °F - Altimeter: 29.82 inHg - Observed at: KBIL, 6 nm away - METAR: KBIL 270153Z 14004KT 10SM CLR 27/M05 A2982 RMK AO2 SLP067 T02671050 ## 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 20210926016399A](https://openairdocs.org/incident/20210926016399A), Sep 26, 2021: Beech S35, Billings, MT, Destroyed, 2 fatal. On September 26, 2021, about 1922 mountain daylight time, a Beech S35 airplane, N354M, was destroyed when it was involved in an accident near Billings,… ## Docket (9 files) The files NTSB released with the investigation on September 20, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103962. 20.8 MB in all. - Witness statements (item 1, PDF, 3 pages, 226 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16030196&FileExtension=pdf&FileName=Witness%20Statements_Redacted-Rel.pdf - Pilot statement (item 2, PDF, 1 page, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16030080&FileExtension=pdf&FileName=pilot%20roc-Rel.pdf - Accident site, airframe, and engine examination (item 3, PDF, 5 pages, 4 photos, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16030288&FileExtension=pdf&FileName=accident%20site%20examination-Rel.pdf - Recovered wreckage examination (item 4, PDF, 3 pages, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16030524&FileExtension=pdf&FileName=recovered%20wreckage%20examination-Rel.pdf - Airport information (item 5, PDF, 2 pages, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16030206&FileExtension=pdf&FileName=airport%20information-Rel.pdf - Statement of party representatives to NTSB investigation (item 6, PDF, 1 page, 245 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16030090&FileExtension=pdf&FileName=party%20form_Redacted-Rel.pdf - Reports from parties to the investigation - Textron (item 7, PDF, 8 pages, 5.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16030298&FileExtension=pdf&FileName=Textron%20Tech%20Report_Redacted-Rel.pdf - Photo array (item 8, PDF, 3 pages, 3 photos, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16030620&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Video of the accident sequence (item 9, MOV, 8.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16030100&FileExtension=MOV&FileName=XRAB6366-Rel.MOV 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.