Pilot Debrief

BEECH A36 near Bentonville, AR — 2016-08-31

Final reportCEN16FA341
Sign in to save
Date
2016-08-31
Location
Bentonville, AR, USA
Airport
VBT
Aircraft
BEECH A36
Registration
N8283D
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

The pilot's failure to monitor and/or transmit his position over the uncontrolled airport's common traffic advisory frequency, and his decision to continue the takeoff when he observed conflicting traffic on the runway.

NTSB narrative

The private pilot was departing from an uncontrolled airport at the same time that another airplane was landing in the opposite direction. Surveillance video showed the accident airplane veer to the left during its takeoff roll, become airborne over a unpaved area between the runway and ramp area, and cross the ramp. The airplane subsequently impacted the top of a hangar and was destroyed by postcrash fire. The video evidence and propeller signatures suggest that the pilot did not reduce power and was attempting to continue the takeoff. An employee at the fixed base operator on the airport reported that she heard the pilot of the landing airplane announce over the airport's common traffic advisory frequency (CTAF) his airplane's position inbound to the airport and his intent to land the airplane at the accident airport; however, neither she nor the pilot of landing airplane heard the accident pilot transmit his position or intentions over the CTAF. The airplane was equipped with communication radios, suggesting that the pilot was not using the radios prior to his takeoff. Examination of the accident airplane did not reveal any preimpact failures or anomalies. Toxicology testing of the pilot revealed the presence of temazepam, a Schedule IV controlled substance of the benzodiazepine class, that is a sedative intended for the short-term treatment of insomnia. The pilot's blood concentration of temazepam was well below that considered to cause significant effects; therefore, it is unlikely the pilot was impaired by this medication at the time of the accident. Additionally, the pilot had atrial fibrillation treated with an anticoagulant and a history of a slow heart rate treated with an implanted pacemaker. The actions of the pilot indicate that he was awake and alert, and there is no evidence to suggest that he was impaired due to his cardiac conditions. It is unlikely that the pilot's atrial fibrillation, high blood pressure, elevated cholesterol, insomnia, or medications used to treat these conditions impaired him or contributed to the accident. It is also unlikely that the pilot's slow heart rhythm treated with a pacemaker contributed to the accident. It is likely that the pilot did not recognize that another airplane was landing in the opposite direction before he initiated the takeoff. When he did see the other airplane during his takeoff roll, rather than abort the takeoff, the pilot veered the airplane off the runway surface and attempted to continue the takeoff, which resulted in collision with the hangar. Federal Aviation Administration guidance states that, in order to achieve the greatest degree of safety, it is essential that all radio-equipped aircraft transmit/receive on a common frequency identified for the purpose of airport advisories. If the accident pilot had been monitoring and/or transmitting over the CTAF, he may have been alerted to the presence of the landing airplane and the accident could have been avoided. In addition, although radio communication is not required at uncontrolled airports, the pilot's failure to use radio communication resulted in his unawareness of the other landing airplane.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have aborted takeoff upon hearing another aircraft on the runway.

NTSB coding

Evidence available

  • Video
  • Photos
  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10

Related mishaps