Pilot Debrief

Beech C24 near Las Vegas, NV — 2019-09-08

Final reportWPR19FA252
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Date
2019-09-08
Location
Las Vegas, NV, USA
Airport
HND
Aircraft
Beech C24
Registration
N24030
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Takeoff roll

Probable cause

The pilot’s operation of the airplane over its maximum gross weight and outside of center of gravity limits at a high-density altitude, which resulted in the exceedance of the airplane's critical angle of attack while maneuvering and subsequent aerodynamic stall at low altitude. Contributing to the accident was the occupants’ failure to ensure the airplane’s doors were secure prior to takeoff.

Contributing factors

Contributing to the accident was the occupants’ failure to ensure the airplane’s doors were secure prior to takeoff.

NTSB narrative

The pilot departed the runway and reported that a door had opened. After clearance to enter the traffic pattern and return to the airport, the airplane climbed to about 100 ft agl and struggled to gain altitude. The airplane turned left and subsequently entered a nose down left bank and impacted the terrain. The airplane sustained substantial damage. As the airplane banked to the left, it likely experienced an aerodynamic stall. Postaccident examination of the propeller blades revealed that the engine was likely operating near high rpm at impact, and examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The pilot’s operating handbook indicated an open door would slipstream and may result in buffeting and that the pilot is to fly the airplane “normally.” The occupants departed earlier the same day in the accident airplane and returned because the airplane was not being able to climb over mountains on their way to their destination. Density altitude was calculated to be 5,437 ft mean sea level at the airport. The airplane was also loaded over the maximum gross takeoff weight and exceeded the aft of the center of gravity limit for both flights. Although the airplane was able to take off, its overweight and aft of CG limit condition and the high-density altitude increased the airplane’s stall speed and degraded its climb performance, stability, and slow-flight characteristics. When the pilot turned the airplane left to return to the airport due to the reported open door, the critical angle of attack was likely exceeded and resulted in an aerodynamic stall at low altitude.

Analysis

Primary failure mode
Human factors
First missed decision gate
Properly securing the entry door before takeoff could have prevented the accident.

NTSB coding

Evidence available

  • ATC audio
  • 15 docket documents
View NTSB final reportView NTSB docket

Docket documents15

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