Pilot Debrief

BEECH C23 near Winder, GA — 2017-02-16

Final reportERA17FA106
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Date
2017-02-16
Location
Winder, GA, USA
Airport
WDR
Aircraft
BEECH C23
Registration
N24695
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Takeoff roll

Probable cause

The flight instructor's inadequate preflight planning and operation of the airplane outside its center of gravity envelope, which resulted in a loss of control while maneuvering.

NTSB narrative

The student pilot, who had recently purchased the airplane, and a flight instructor were conducting a local instructional flight. Another pilot reported that, while approaching the airport for landing, he heard an airplane (likely the accident airplane) announce over the common traffic advisory frequency that they would be departing runway 31; however, he did not see the airplane depart. A witness, who was driving on a highway near airport, observed the accident airplane fly in front of her heading south/southeast. She stated that the airplane seemed to be flying low and fast as it went over the highway. It then began to nose down, then level out, and "tilt to the right." The witness then lost sight of the airplane behind trees. The airplane impacted trees and terrain on a southeasterly heading about 500 ft west of the departure end of runway 31 (the runway 13 threshold). Given the location and orientation of the wreckage, it is possible that the flight instructor and student departed runway 31 and were attempting to return to the airport to land on the opposite runway (13) when they experienced a loss of control. As the airplane turned back toward runway 13, the pilots would have encountered an 8-knot gusting to 14-knot tailwind, which would have increased the airplane's ground speed and closure rate with terrain and obstacles surrounding the airport and the runway. Weight and balance calculations revealed that, although the airplane was operating below its maximum gross weight at the time of the accident, its center of gravity (CG) was forward of the limit established by the manufacturer. Since airplane stability and control are affected by improper balance, exceedance of the forward limit would likely have resulted in a nose-heavy condition and difficulty in controlling and raising the nose, especially during takeoff and landing. Although the reason for the decision to land on the opposite runway could not be determined, it is likely that the airplane's forward CG affected its control characteristics and that the trim required to help relieve the control forces imposed by the forward CG may have resulted in reduced pitch control travel at the lower airspeeds required for approach and landing. Examination of the airplane and engine did not reveal evidence of any preimpact malfunctions or failures that would have precluded normal operation. There was evidence of fuel onboard, and the lack of airframe, flight control, and engine anomalies were also consistent with a loss of control event. Toxicology testing revealed that the flight instructor had used amphetamine at some time before the flight, but whether the drug was being used to treat an underlying condition such as attention-deficit/hyperactivity disorder (ADHD) or narcolepsy, or whether he had used the amphetamine illicitly to get high and was in/or entering the withdrawal phase of use, also could not be determined. Overall, whether the flight instructor's use of amphetamine or effects from an underlying medical condition contributed to the accident circumstances could not be determined.

Analysis

Primary failure mode
Human factors
First missed decision gate
Proper weight and balance calculations before takeoff could have prevented the accident.

NTSB coding

Evidence available

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

Docket documents12

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