Pilot Debrief

BEECH A36TC near Kalamazoo, MI — 2009-10-27

Final reportCEN10FA029
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Date
2009-10-27
Location
Kalamazoo, MI, USA
Airport
AZO
Aircraft
BEECH A36TC
Registration
C-FFIH
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

The loss of engine power for an undetermined reason.

NTSB narrative

Witnesses and global positioning system data indicated that after takeoff the airplane tracked the runway centerline and climbed approximately 150 feet above ground level before turning to the right and descending. The airplane subsequently impacted the ground, a fence, and a pole about 1,400 feet from the departure end of the runway. A postimpact fire ensued. After acknowledging the takeoff clearance, no further communications were received from the accident airplane. Examination of the airplane’s structure, flight controls, engine controls, and fuel system did not reveal any anomalies consistent with a preimpact failure. The engine manufacturer had issued a Mandatory Service Bulletin (MSB) that was applicable to the accident airplane’s engine. The airplane’s engine was disassembled in order to replace components damaged during the impact sequence. During the disassembly the valve lifters that were the subject of the MSB were examined and found to have pitting. However, the engine was reassembled with the original valve lifters for a functional test run and during the test run the engine produced full rated power and no anomalies were noted. Data retrieved from an engine monitoring system installed on the accident airplane recorded a significant reduction in engine power during the accident takeoff. The monitoring system did not record throttle, mixture, or propeller control positions and the data was consistent with normal power reductions recorded during the landing phase of previous flights. No mechanical reason for the loss of engine power was found.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have aborted takeoff upon noticing engine power reduction.

NTSB coding

Evidence available

  • ATC audio
  • Photos
  • 11 docket documents
View NTSB final reportView NTSB docket

Docket documents11

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