Pilot Debrief

BEECH C23 near Osage Beach, MO — 2016-10-22

Final reportCEN17FA024
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Date
2016-10-22
Location
Osage Beach, MO, USA
Airport
AIZ
Aircraft
BEECH C23
Registration
N20087
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Takeoff roll

Probable cause

The pilot's loss of control while maneuvering shortly after takeoff. Contributing to the loss of control was the pilot's attempt to climb with the flaps fully extended.

Contributing factors

Contributing to the loss of control was the pilot's attempt to climb with the flaps fully extended.

NTSB narrative

The commercial pilot was flying his newly purchased airplane across the country to his home. After a flight of about 560 nautical miles that would have taken about 5 hours and consumed at least 51 gallons of the airplane's 58.8 usable gallons of fuel, an airport employee heard the pilot on the common traffic advisory frequency (CTAF) announcing his intention to land. The airplane landed but did not taxi to the ramp. The employee attempted to communicate with the pilot over the CTAF, but the pilot's transmissions were garbled. The airplane then departed on runway 4, and the employee heard no further transmissions from the pilot. No witnesses to the accident were identified. The wreckage was discovered in a heavily wooded area about 1,000 ft east of the departure end of runway 4, a location consistent with the pilot turning right during initial climb before the airplane descended and impacted terrain. A postaccident examination of the airplane and engine did not find any anomalies that would have precluded normal operation. The wreckage distribution and impact damage indicated that the airplane collided with the trees in a nose-low attitude consistent with a loss of control. Damage to the wings precluded an accurate measurement of the fuel on-board the airplane; however, fuel was found in the carburetor bowl and fuel pump, and damage to several tree branches was consistent with the engine operating when the airplane collided with trees. The flaps were found fully extended, which is the proper setting for landing. For takeoff, the airplane's flaps should have been in the fully retracted position, and the extended flaps would have added a significant amount of drag and degraded the airplane's climb performance. It is likely that the pilot forgot to retract the flaps after landing at AIZ and attempted to take off with them extended

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot did not refuel before departing from AIZ despite insufficient fuel for the flight.

NTSB coding

Evidence available

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

Docket documents6

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