Pilot Debrief

BEECH E35 near Buckeye, AZ — 2022-06-18

Final reportWPR22FA215
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Date
2022-06-18
Location
Buckeye, AZ, USA
Airport
KBXK
Aircraft
BEECH E35
Registration
N13AR
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Approach

Probable cause

The pilots’ failure to climb and complete a normal traffic pattern after making a low approach and their failure to extend the flaps for reasons that could not be determined, and the flight instructor’s failure to ensure adequate airspeed and bank control during the turn to final approach, which resulted in an accelerated stall.

NTSB narrative

The flight instructor and student pilot departed the airport where the airplane was based and proceeded to another airport, flying a flight profile consistent with flight training. They flew one straight-in approach to a low approach over the runway, about 200 ft above ground level (AGL). Following the low approach, the airplane made a right turn to downwind about midway down the runway. The airplane did not climb during the turn or after it was established on downwind. It remained 200-300 ft AGL and maintained airspeed at or near the 45° bank no-flap stall speed. The airplane then angled towards the extended runway centerline and began a turn to final shortly after passing abeam the runway threshold. The airplane subsequently impacted terrain in the turn and short of the runway. A postimpact fire ensued and the airplane was destroyed. There were no witnesses to the accident. The airplane impacted terrain in a near-vertical and left-wing-low attitude, consistent with impact following a stall. Postaccident examination of the wreckage and engine revealed no preimpact anomalies and damage to the propeller blades was consistent with the engine producing power at the time of impact. The flaps were found in the retracted position, contrary to normal landing procedures that specify the flaps should be extended. The student pilot had heart disease and had used a medication that increased his risk of having a sudden impairing or incapacitating cardiac event such as arrhythmia or heart attack. There is no autopsy evidence that such an event occurred, although such an event does not reliably leave autopsy evidence if it occurs just before death. Operational evidence in this case makes a sudden medical event involving the student pilot unlikely. Had such an event occurred with the student pilot flying, the flight instructor would have been available to assist in maintaining airplane control. Additionally, the airplane’s flight path prior to the accident indicates the airplane was being flown in a controlled manner. Due to the limitations of the instructor’s toxicological testing, the results of that testing cannot be reliably interpreted. Thus, there is insufficient toxicological evidence to determine whether the instructor had used any substances that were potentially impairing or indicative of potentially impairing underlying conditions. The airplane was flown in a non-standard traffic pattern at an unusually low altitude that positioned the airplane closer to the runway than normal during the final turn. Additionally, the airplane flaps were found in the retracted position. It could not be determined why the non-standard traffic pattern was flown or why the flaps were retracted, but both conditions increased the susceptibility of an accelerated stall during the turn to final. It was not determined which pilot was manipulating the controls at the time of the accident, but the evidence indicates the pilot flying maneuvered the airplane such that an accelerated stall occurred. The flight instructor was responsible for the safe operation of the airplane, but he did not ensure proper airspeed or bank control during the turn to final.

Analysis

Primary failure mode
Human factors
First missed decision gate
Failure to maintain proper altitude and speed during approach to runway 17.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 12 docket documents
View NTSB final reportView NTSB docket

Docket documents12

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