Pilot Debrief

BEECH 95-B55 near LaGrange, GA — 2014-02-22

Final reportERA14FA128
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Date
2014-02-22
Location
LaGrange, GA, USA
Airport
LGC
Aircraft
BEECH 95-B55
Registration
N36638
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Approach

Probable cause

The pilot's overreaction to a perceived conflict with a tow plane and glider on an intersecting runway, which resulted in a loss of control during an attempted aborted landing. Contributing to the accident was the failure of the glider tow operator to follow and the airport operator to ensure compliance with published airport rules and regulations for glider tow operations.

Contributing factors

Contributing to the accident was the failure of the glider tow operator to follow and the airport operator to ensure compliance with published airport rules and regulations for glider tow operations.

NTSB narrative

The accident airplane was inbound to the airport, conducting an instrument approach in visual meteorological conditions, when the pilot announced its position over the airport's common traffic advisory frequency (CTAF). Witnesses described the accident airplane's approach as fast and stated that the airplane never touched down. The accident airplane's engines then rapidly accelerated to full power before the airplane pitched up into a steep climb, banked left, rolled inverted, and struck the ground in a nearly vertical nose-down attitude, about 3,600 feet down the 5,599-foot-long runway. Throughout the morning of the accident, glider operations were being conducted on an intersecting runway. As the accident airplane floated down the runway, witnesses observed a tow plane accelerating down the intersecting runway with a glider in tow; The tow plane pilot then announced over the CTAF, "abort abort abort." The glider was then released from the tow plane and landed undamaged on the runway prior to the intersection of the two runways, while the tow plane crossed over the intersecting runway before taxiing back to the ramp. Examination of the wreckage revealed no preimpact mechanical anomalies. According to witnesses on the airport, neither the glider nor tow plane appeared to be in immediate conflict with the accident airplane just before the accident; they stated that the accident pilot could have safely continued the landing. Additionally, the three pilots onboard the accident airplane had flown into the airport earlier in the day and were aware of the glider operations being conducted on the other runway. However, the accident pilot's observed reaction, as evidenced by the sudden application of full engine power followed by the airplane's abrupt increase in both pitch attitude and bank angle, suggest that he may have been surprised by the appearance of the glider and tow plane in his field of vision and perceived an imminent collision. The FAA airport manual contained advisories for glider operations at the accident airport. Examination of the airport rules and regulations, published on the airport website, revealed that a local notice to airmen (NOTAM) was required to be filed prior to the conduct of glider operations. Additionally, a "spotter" was prescribed to be used during glider operations, positioned in a location from which the entire length of the intersecting runway could be viewed, in order to avoid conflicts with other aircraft. According to the airport rules and regulations, the tow plane and glider were prohibited from taking off without approval from the spotter. On the day of the accident, no NOTAM had been filed regarding the day's glider operations, nor was a spotter being used. Interviews with the glider operator revealed a widespread lack of knowledge regarding these published rules. Furthermore, while airport management was aware of the rules with regard to glider operations, there was no method in place to ensure compliance with the published risk management practices.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Pilot could have executed a go-around instead of attempting to land long.

NTSB coding

Evidence available

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

Docket documents18

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