Pilot Debrief

Beech B36TC near Corona, CA — 2020-01-22

Final reportWPR20FA072
Sign in to save
Date
2020-01-22
Location
Corona, CA, USA
Airport
AJO
Aircraft
Beech B36TC
Registration
N36TT
Category
Airplane
Highest injury
Fatal
Fatalities
4
Phase of flight
Takeoff roll

Probable cause

The pilots’ failure to abort the takeoff, which resulted in a collision with a fence at the end of the runway. Contributing to the accident was the airplane being at or over the maximum gross takeoff weight and the inappropriate elevator trim tab setting.

Contributing factors

Contributing to the accident was the airplane being at or over the maximum gross takeoff weight and the inappropriate elevator trim tab setting.

NTSB narrative

The airplane, with two pilots and two passengers onboard, had landed at the airport to refuel, and 78.06 gallons of fuel were added. The airplane departed with a 5-knot tailwind down a 3,200 ft asphalt runway. According to a witness at the airport, the nose raised off the runway surface prematurely during the takeoff roll. Although the investigation could not determine which pilot was at the controls, neither pilot elected to abort the landing and the airplane bounced down the runway unable to become airborne. The airplane continued to accelerate and reached rotation speed as it collided into a fence at the end of the runway. Onsite examination revealed the elevator trim tabs were in the full-down position (full nose-up trim). It is likely the elevator trim was mistakenly set at full nose-up trim, which enabled the nose to rise off the runway surface prematurely during the takeoff roll. As the airspeed increased, the force required to push the nose down would have become greater. The right-seated pilot owned the airplane and the left-seated pilot had flown with him before. A review of the left-seated pilot’s personal notebook revealed that he had flown 3.7 hours in the accident airplane and therefore, likely had limited familiarity with it. Although the airplane was likely at or over the maximum gross weight based on the amount of fuel added to the airplane, the airplane’s performance charts indicate that the runway length was sufficient at the airplane’s maximum gross takeoff weight to complete a takeoff. Both pilots had ample opportunity to abort the takeoff when they realized the airplane was not becoming airborne but continued with the takeoff attempt.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Pilot could have aborted takeoff after initial bounce and loss of control.

NTSB coding

Evidence available

  • Video
  • 7 docket documents
View NTSB final reportView NTSB docket

Docket documents7

Related mishaps