Pilot Debrief

BEECH 58 near St. Ignace, MI — 2010-07-13

Final reportCEN10FA394
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Date
2010-07-13
Location
St. Ignace, MI, USA
Aircraft
BEECH 58
Registration
N3081N
Category
Airplane
Highest injury
Fatal
Fatalities
4
Phase of flight
Takeoff roll

Probable cause

The pilot's failure to maintain aircraft control during takeoff for undetermined reasons.

NTSB narrative

Witnesses observed the airplane abort two takeoffs prior to the accident takeoff. During the second and third (accident) takeoff rolls, one engine did not sound like it was developing full power. In between the three takeoff attempts, the pilot did not perform an engine run-up. During the accident takeoff roll, one engine still did not sound like it was developing full power and the airplane rotated shortly before the end of the runway. The airplane briefly became airborne, with the wings rocking back and forth, and then impacted an interstate highway with its left wing, which was consistent with an aerodynamic stall. The airplane impacted a cable median barrier and a fire ensued. The airplane continued into a ditch, nosed over, and came to rest inverted. A postaccident examination of the airframe and engines revealed no anomalies that would have precluded normal operation. The pilot had some moderate heart disease and sleep apnea that were documented in his medical records. Toxicology findings noted the use of an unreported medication (atenolol) that was taken at an undetermined time prior to the accident. Approximately 10 minutes prior to the accident flight, the pilot amended his instrument flight rules clearance with an air traffic controller via the airplane's radio. No problems with the pilot's conversation or speech were noted during the recorded transmissions, and the investigation could not conclusively determine whether the pilot's medical conditions or medication use were related to the accident.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot should have conducted an engine run-up before takeoff attempts.

NTSB coding

Evidence available

  • Photos
  • 13 docket documents
View NTSB final reportView NTSB docket

Docket documents13

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