Pilot Debrief

BEECH 19A near Oroville, CA — 2022-06-02

Final reportWPR22FA196
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Date
2022-06-02
Location
Oroville, CA, USA
Airport
OVE
Aircraft
BEECH 19A
Registration
N7641R
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Takeoff roll

Probable cause

The pilot’s failure to maintain proper airspeed during a turn and his exceedance of the airplane’s critical angle of attack, which resulted in an accelerated stall. Contributing to the accident was the improper placement of the fuel selector, which resulted in fuel starvation and a partial loss of engine power.

Contributing factors

Contributing to the accident was the improper placement of the fuel selector, which resulted in fuel starvation and a partial loss of engine power.

NTSB narrative

The accident pilot was a partial owner of the accident airplane, which had not flown for several months until he attempted to fly the airplane about 2 weeks before the accident. During this previous flight the pilot and his student were forced to abort two takeoff attempts after the airplane failed to climb. The pilot and pilot-rated passenger, who was also a flight instructor, had planned to fly the airplane on the day of the accident to troubleshoot the performance deficiency. During takeoff on the accident flight, the airplane reached an intermediate altitude before it started to settle momentarily. The airplane then continued to climb to a peak altitude of about 100 ft above ground level and then it started a right turn that progressively became steeper. Subsequently, the airplane impacted the ground in a nose-down attitude. An analysis of the engine harmonics during takeoff suggested that the engine may have encountered anomalies when the airplane began its right turn, but this could not be substantiated as postaccident examination of the airframe and engine did not reveal any preimpact mechanical anomalies. The fuel selector was found between the RIGHT tank detent and the OFF position at the accident site. During the flight 2 weeks earlier the accident the pilot had placed the handle in a similar position before takeoff. As there were no preimpact mechanical anomalies with the engine, it is likely that the improper placement of the fuel selector in the OFF position during takeoff resulted in fuel starvation and a partial loss of engine power. Performance computations indicated that the airplane was capable of a successful takeoff as it was below its maximum gross weight. The airplane’s center of gravity (CG) was nose-heavy, which likely would have resulted in difficulty in lifting the nose during takeoff and during reduced power situations. However, this CG condition is only likely to have affected takeoff and likely did not contribute to the accident. Recorded data suggests the airplane entered an accelerated stall in the turn when it exceeded the critical angle of attack without maintaining adequate airspeed. The investigation was unable to determine if the pilot-rated passenger was aware of the airplane’s takeoff issues 2 weeks before the accident. It is also unclear who was piloting the airplane in its final moments; however, the pilot was likely flying at the time considering he was a part owner in the airplane and given his motivation to troubleshoot the performance deficiency. While cardiovascular conditions placed the pilot at an increased risk for a sudden cardiac event, operational evidence does not suggest that this occurred and was likely not a factor in this accident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot ignored concerns about airplane not wanting to fly before takeoff.

NTSB coding

Evidence available

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

Docket documents20

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