Pilot Debrief

AERO COMMANDER 200D near Novato, CA — 2024-08-31

Final reportWPR24FA290
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Date
2024-08-31
Location
Novato, CA, USA
Airport
DVO
Aircraft
AERO COMMANDER 200D
Registration
N2912T
Category
Airplane
Highest injury
Fatal
Fatalities
1

Probable cause

The pilot’s failure to abort takeoff or compensate for gusty crosswind conditions during takeoff, which resulted in a loss of control and subsequent runway excursion.

NTSB narrative

Multiple witnesses described the airplane crossing over into the runway safety area shortly after the pilot’s takeoff roll on a personal flight in his single-engine airplane. The airplane crossed over a taxiway and into another runway safety area before crossing the ramp in a nose-high pitch attitude. The airplane was unable to outclimb the nearby hangars as it approached them, subsequently impacting the end hangar. A postaccident fire ensued. About 15 minutes before the pilot departed, the wind conditions for the departure runway were reported as variable between 190° to 270° with gusts to 14 knots, with the prevailing wind from 240° at 7 knots. About 5 minutes after the accident, the reported wind conditions were from 220° at 9 knots. Additionally, other pilots at the airport at the time of the accident reported gusting and variable wind conditions. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Given the left-turning tendency due to engine torque and P-factor, combined with the left crosswind and gusts during the time of the accident, exacerbated the runway excursion. The pilot was likely unable to maintain directional control during takeoff due to these combined factors, resulting in the airplane departing the runway and entering the runway safety area. The takeoff was not aborted for unknown reasons. In the setting of a post-crash fire and smoke inhalation, the pilot’s elevated carboxyhemoglobin level does not constitute evidence that the pilot was impaired by carbon monoxide during the flight. The pilot’s cardiovascular disease, including severe coronary artery disease, placed him at substantially increased risk of an impairing or incapacitating cardiovascular event, such as chest pain, arrhythmia, or heart attack. There is no autopsy evidence that such an event occurred; however, such an event does not leave reliable autopsy evidence if it occurs just before death. Notably, even severe coronary artery disease may not cause major symptoms.

NTSB coding

Evidence available

  • 8 docket documents
View NTSB final reportView NTSB docket

Docket documents8

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