NTSB Factual Report

HISTORY OF FLIGHT

On July 26, 2012, about 0830 mountain standard time, a Beech B60, N880LY, serial number P-524, was destroyed during a runway overrun following takeoff roll at the Sedona Airport (SEZ), Sedona, Arizona. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91. The private pilot and two passengers were fatally injured. Visual meteorological conditions prevailed for the planned personal cross-country flight, and no flight plan was filed. The destination was reported to be the Double Eagle II Airport (AEG), Albuquerque, New Mexico. The flight was originating at the time of the accident.

During the investigation four individuals provided the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) with written statements relative to their observations of the accident sequence:

Witness #1, a retired Federal Aviation Administration (FAA) operations supervisor, stated that he was located about 200 feet north of the parallel taxiway and about 1,000 feet southwest of the approach end of Runway 21; he had an unobstructed view of the entire runway. The witness reported that he initially observed the airplane doing a run-up in the run-up area adjacent to Runway 21, that the engines sounded normal, and that the time it took the pilot to complete the run-up was normal. The airplane then took Runway 21 for departure, and the acceleration during the takeoff roll appeared a little slower than normal. The witness added that the engines sounded normal, that directional control was normal, and at mid-field the airplane was still moving on the ground and had not rotated. The witnesses opined, "At that time I began to be concerned." The witness stated that as the airplane continued down the runway it appeared that it wasn't accelerating. The witness further stated that about 100 yards from the departure end of Runway 21 it appeared that the airplane wasn't going to stop. During this time the airplane maintained runway contact and directional control. The witness added that as he observed the airplane go off the end of Runway 21, it appeared to turn slightly to the right, and at the same time he heard a mild bang and the airplane went out of sight. About 30 seconds after losing sight of the airplane, a very large black mushroom cloud, about 200 to 300 feet high, appeared.

Witness #2, who resided at the north end of the departure runway, stated that on the morning of the accident he was sitting outside when he heard an airplane start its takeoff roll, seemingly losing power for a moment and then regaining it; it was not a "run-up". The witness reported that the airplane was definitely taking off, that the drone of the engine was lowered for an instant, and then regained what he thought was a "normal" sound for an engine at full operating power.

Witness #3 reported that while driving along the airport ramp on the north side of the airport, he observed the accident airplane stationary and on the numbers of Runway 21, apparently preparing to take off. The witness further reported that it appeared to him that the left engine was turning at a slower revolutions per minute (rpm) than the right engine, "…as I could see the prop blades on the left engine." The witness stated that the airplane seemed to be holding in the takeoff position for what he considered to be a longer than normal amount of time. The witness opined that he estimated that from the time he first observed the airplane holding on the runway to the start of the takeoff [roll], at least 1 minute had elapsed. He added that it was his impression at the time that there was some type of an abnormal situation with the airplane due to the slow rpm of the left engine and its extended hold time on the runway. The witness revealed that he then heard the airplane power up to what sounded like full power and start its takeoff roll; the witness stated that he was about 200 to 250 feet from the numbers of Runway 21 at this time. The witness stated that in his opinion both engines sounded normal, with a slight out-of-sync beat, and no different from other twin-engine airplanes of this type at full takeoff power. As the accident airplane passed by his position it accelerated on its takeoff roll, and out of the witness's sight, in what appeared to be a normal takeoff. He subsequently looked around the hangars, and saw the large black plume of smoke.

Witness #4, the Airport Operations Manager, reported that while driving to the north end of the airport to perform maintenance, he entered the taxiway at A-3 behind the accident airplane, which was taxiing to the run up area for Runway 21. On returning via the taxiway, he passed the accident airplane that was on its takeoff roll between A-2 and A-3, and exchanged a hand wave, with whom he believed was the pilot, but could not be entirely certain that it was actually the pilot with whom he exchanged the wave. The witness stated that he subsequently observed the smoke plume coming from the southwest end of the airport, and immediately responded to the accident site, where he observed that the airplane had been consumed by the post-impact fire.

During the investigation local law enforcement personnel provided the NTSB IIC with two additional statement of individuals who had witnessed the accident. Their statements revealed the following:

Witness #5 reported that while towing a helicopter in close proximity to taxiway A-4 he observed the twin-engine airplane taxi into position for departure on Runway 21. As he reached taxiway A-3, he observed the airplane pass his position at a fairly fast rate of speed; the engines were at takeoff throttle and running normal. The witness continued to watch the airplane as it proceeded past taxiways A-5 and A-6, at which time he began to wonder why the pilot had not started to rotate. The witness stated that it appeared to him that the airplane was going at a high rate of speed as it passed [taxiway] A-8. At this time, the witness was at taxiway A-4 and could not detect any engine sound or deceleration [of the airplane]. He continued to watch the airplane as it went off the end of the runway and disappear from sight.

Witness #6 reported that on the morning of the accident she was hiking on the airport loop trail east when she heard the airplane start its takeoff. Shortly thereafter she observed the airplane approaching the end of the runway, and it appeared that it was going to hit the [airport's perimeter] fence. The witness stated that she could hear the engines cutting out before it hit the fence, and that they were cutting out more when the airplane crashed into some big trees.

The airplane wreckage was consumed by the postcrash fire, and was located at the bottom of a steep drop-off at the end of Runway 21.

The airplane was recovered to a secure location for further examination.

PERSONNEL INFORMATION

The pilot, age 53, held a private pilot certificate with ratings for airplane single-engine and multiengine land, and instrument airplane. The pilot's most recent third-class FAA airman medical certificate was issued on January 5, 2011, without limitations.

A review of the pilot's computerized logbook records, which were supplied to the NTSB IIC by a family member, revealed that as of July 14, 2012, the pilot had accumulated a total flying time of 663 hours, of which 545 hours were in single-engine airplanes, and 118 hours were in multiengine airplanes. The logbook review further revealed that the pilot had accumulated a total of 62 hours in the accident airplane make and model. It was also noted that the pilot had completed 6 flights into SEZ between March 29, 2011 and May 28, 2012, each in the accident airplane. In the previous 90 days, 30 days, and 24 hours prior to the accident, the pilot had flown a total of 23.2 hours, 5.1 hours, and 0 hours respectively, both in single-engine and multiengine airplanes. Additionally, the pilot had flown the accident airplane 9 hours and 3 hours respectively in the preceding 90 days, 30 days, and 24 hours prior to the accident.

A review of the pilot's training records provided by the SIMCOM Training Center, Scottsdale, Arizona, indicated that the pilot had satisfactorily completed the B60 initial training course on March 6, 2011. Additionally, the pilot had completed his most recent B60 recurrent training on March 23, 2012. In an interview conducted with the accident pilot's simulator instructor on August 15, 2012, the instructor revealed that the pilot was very attentive during training, knew the airplane well, was very disciplined, and was a very good student.

AIRCRAFT INFORMATION

The airplane was a Beechcraft model B60, six seat, low-wing, retractable gear airplane, serial number P-524, which was manufactured in 1979. The airplane was powered by two Lycoming TIO-541-E1B4, 380-horsepower engines that were equipped with Hartzell constant-speed, full-feathering, three-bladed propellers.

A review of the airplane's maintenance records revealed that the most recent documented annual inspection was performed on April 9, 2012, at a total airframe time of 3,915.23 hours,and a Hobbs time of 437.3 hours. At the time of the accident, the airplane had been operated about 11 hours since its most recent annual inspection.

Maintenance records also revealed that on September 18, 2008, at an airframe total time of 3,740.5 hours and a Hobbs time of 262.5 hours, Midwest Aviation Services, Inc., Oskaloosa, Iowa, installed a TIO-E1B4 Lycoming engine, serial number L-192-59C in the left position, and a TIO-E1B4 Lycoming engine, serial number L-196-59C in the right position. At the time of installation, both engines had a total time of 2,716.8 hours, a total time since major overhaul of 45.5 hours, and a Hobbs time of 262.5 hours. At the time of the accident, each engine had accumulated about 220 hours since the most recent overhaul.

METEOROLOGICAL INFORMATION

At 0835, the SEZ Automated Weather Observing System (AWOS) reported wind calm, visibility 10 miles, sky clear, temperature 26 degrees Celsius (C), dew point 13 degrees C, and an altimeter setting of 30.17 inches of mercury. The density altitude at the time of takeoff was calculated to be 7,100 feet.

WEIGHT AND BALANCE

During the investigation, a Beechcraft air safety investigator provided the NTSB IIC with computed weight and balance data that revealed at the time of the accident the airplane was within its center of gravity limits, and was below its maximum gross takeoff weight for the planned flight.

PERFORMANCE

During the investigation, a picture of the airplane on its takeoff roll was provided by an unidentified visitor standing on the south side of the airport restaurant looking south toward the runway. An examination of the photograph revealed that the accident airplane was just approaching taxiway A5, or about 2,500 feet from the start of Runway 21. A Beechcraft air safety investigator calculated that the airplane would liftoff at 2,805 feet, and that a takeoff distance of 3,550 feet would have been required to have cleared a 50 foot obstacle. The normal takeoff and initial climb speed would have been 94 knots. Additionally, it was noted that the Accelerate Stop Distance would have been about 4,600 feet from the start of the takeoff roll to a full stop. The length of Runway 21 is 5,132 feet.

WRECKAGE AND IMPACT INFORMATION

The airplane traveled the length of Runway 21, then across the asphalt and dirt overrun of 175 feet before impacting the top of an airport perimeter fence and descending into a deep gully. The airplane impacted the bottom of the gully, and was destroyed as a result of impact forces and a postaccident fire.

Two distinct tire tracks were observed on the departure end of Runway 21, both of which travelled across the asphalt surface of the Runway 03 displaced threshold and the dirt overrun. The measured tire tracks were about 11 feet apart, with the left-most track aligned with the runway centerline; the B60 wheel span is 11 feet 3 inches when sitting on the ground and in a stationary position. A black contact mark, which resembled a mark made by the tire sidewall, was observed on the left side of a bent-over fence post. The left-most tire track ended just prior to the bent-over fence post.

The entire airplane wreckage was located at the bottom of the gully. The drop in elevation from the airport perimeter fence to the bottom of the gully was 273 feet. The horizontal distance travelled was 672 feet. The vegetation observed on the slope was disturbed at a point about 50 feet above the wreckage location, but no airplane parts were found at that location, nor were there any ground scars that could be evaluated.

The fuselage, cabin, and center wing section was at rest in an upright orientation on a measured magnetic heading of 165 degrees. A postimpact fire had consumed the majority of the airplane, leaving only some of the heavier aluminum structure and steel components identifiable. Both engines remained connected to their respective nacelles. Both propellers were separated from their respective engines.

The roof and sidewalls of the cabin and the rear fuselage were observed to have been partially consumed by fire; the rear fuselage was separated from the cabin area. The nose area forward of the front pressure bulkhead was crushed and partially consumed by fire. The instrument panel and center console were partially consumed by fire.

An examination of the fuel selector panel revealed that the left fuel selector knob was positioned to the six o'clock position, which is not a selectable position; it was rotated with finger force. The right fuel selector knob was positioned to the twelve o'clock position, which is the ON position; it would not rotate with finger force. The cable control attached to the left fuel selector knob was separated. The cable control remained attached to the left fuel selector valve mounted on the aft side of the front spar in the left wheel well; the valve had been exposed to thermal damage. The right fuel selector cable remained attached to the fuel selector valve assembly and the fuel selector knob.

The left wing was partially consumed by fire and lay forward of the cabin area. It was also partially separated from the front and aft carry-through spar. The left engine was partially separated from the left wing and was lying inverted and forward of the wing. The engine had been damaged by thermal activity. The propeller was separated from the engine crankshaft. The left flap actuator was separated from the wing structure mount. The actuator body and nut had been consumed, which prevented the flap actuator position from being determined. An inboard section of the flap was partially consumed by fire, and was in a retracted position.

The right wing was partially consumed by fire, and remained partially attached to the carry-through spar. The flap actuator body and nut had been consumed preventing the flap actuator position from being determined. The right engine was partially attached to the right wing, and had sustained fire damage.

The empennage was mostly consumed by fire. The elevator trim actuator and rudder trim actuator were located, and the actuator extension measured. The rudder trim actuator extension was 3-3/8 inches, which corresponds to a neutral tab position. The elevator trim actuator extension was 4-11/16 inches, which corresponded to a neutral tab position. The aileron actuator extension indicated that the left aileron trim tab was positioned 2 degrees trailing edge down.

The flight control cables controlling pitch, yaw and roll were examined. The examination revealed that all cables had continuity from the cabin control assemblies to the respective flight control bellcranks; all bellcranks were partially consumed by fire. Trim cables had continuity from the cabin area to the elevator and rudder control surface areas.

The nose landing gear and strut assembly had impact and fire damage and remained partially attached to the cabin area. The main landing gear wheel and strut assemblies had separated, and were found in the area of the main wreckage. The landing gear extension rods separated from the landing gear actuator drive bellc

NTSB Probable Cause

The airplane’s failure to rotate and the pilot’s failure to reject the takeoff, which resulted in a runway overrun for reasons that could not be undetermined because postaccident examination of the airplane and engines did not reveal any malfunctions or failures that would have precluded normal operation.