NTSB Factual Report

HISTORY OF FLIGHT

On May 28, 2013, about 1143 mountain standard time, a Beechcraft A36, N999PK, was destroyed when it impacted trees and terrain in the Coconino National Forest adjacent to Mountainaire, Arizona, shortly after takeoff from Flagstaff Pulliam airport (FLG), Flagstaff, Arizona. A large post-impact fire ensued immediately. The owner/private pilot and the one passenger received fatal injuries. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the flight.

According to relatives of the pilot, he based the airplane at McClellan Airfield (MCC) Sacramento, California. The pilot and his wife (the passenger) departed MCC on the morning of May 25, 2013, and arrived at FLG that same day. According to personnel and documentation from a fixed base operator (FBO) at FLG, the couple rented a car the day they arrived, and returned the car to the FBO about 1100 on the day of the accident. On their return, the pilot requested that 20 gallons of fuel be loaded into each of the main tanks, and then queried the FBO owner for about 15 minutes about route and other considerations for a flight to Bryce Canyon Airport (BCE), Bryce Canyon, Utah. The airplane was refueled, and the pilot and his wife loaded their belongings into the airplane.

According to the communications recordings from the FLG air traffic control tower (ATCT), after startup and taxi out, the pilot requested and was granted a turnout to the northeast. The airplane took off from runway 21, and was observed to be climbing very slowly by a pilot in a Cessna 172, which departed shortly after the Beechcraft.

According to the Cessna pilot, once it was beyond the end of the runway, the Beechcraft followed a slightly meandering course initially to the south, and then turned further left towards the south-southeast. The Cessna pilot then witnessed the Beechcraft impact trees adjacent to a semi-rural neighborhood about 3 miles from FLG. The Cessna pilot reported the accident to the ATCT controller. The terrain between the airport and the accident site was forested, gently undulating, and generally lower than the airport.

Several residents of the accident neighborhood were outside, and witnessed the final portion of the flight. Most reported that the engine was making "popping" noises, and was not trailing any dark smoke. Some of those eyewitnesses were the first responders to the accident. They immediately began fire suppression efforts using portable fire extinguishers, shovels of dirt, and household/garden hoses. All those individuals reported that the fire was large and intense, but that their efforts were partially successful in suppressing or containing the fire.

PERSONNEL INFORMATION

Federal Aviation Administration (FAA) records indicated that the 59-year-old pilot held a private pilot certificate with an airplane single-engine land rating. That certificate was issued in May 2010. The pilot's most recent FAA third-class medical certificate was issued in September 2012. On the application for that medical certificate, the pilot indicated that he had a total flight experience of 540 hours.

FAA records indicated that the pilot purchased a turbo-charged Cessna 182 in December 2008; he retained that airplane, and purchased the non-turbocharged accident airplane (Beechcraft) in November 2011.

The pilot's fire-damaged flight logbook was recovered from the wreckage. Review of the logbook indicated that the pilot began flight training in 2008, and that at the time of the accident, had accumulated about 611 total hours of flight experience. The logbook indicated that the pilot completed a flight review in the Cessna in February 2013. Damage to the logbook precluded a determination of the pilot's total flight experience in each airplane.

The pilot's nephew stated that the Cessna was "not flown much" subsequent to the purchase of the Beechcraft. The nephew also reported that the pilot was familiar with high elevation airports, and noted that the pilot flew into Truckee California "regularly." Truckee-Tahoe airport (TRK) has an elevation of 5,901 feet above mean sea level (msl).

The pilot had flown the Beechcraft with at least two different certified flight instructors (CFI). The first CFI flew a total of about 33 hours in the airplane with the pilot; their first flight together was to transport the airplane from Colorado to California following the pilot's purchase of the airplane. Subsequent flights were conducted initially to satisfy insurance requirements, and then to increase the pilot's proficiency with the airplane. The second CFI began flying with the pilot in May 2012, when the pilot began training for an instrument rating. That CFI flew a total of about 3 hours with the pilot in the accident airplane.

MEDICAL AND PATHOLOGICAL INFORMATION

The Coconino County (Arizona) Office of the Medical Examiner autopsy report indicated that the cause of death was "thermal injuries." The FAA Civil Aeromedical Institute conducted forensic toxicology examinations on specimens from the pilot, and reported that no cyanide or ethanol was detected. The reported blood carbon monoxide level was 15 percent. Alpha-hydroxyalprazolam, a metabolite of alprazolam (trade name Xanax), was detected at a level of 0.009 micro-grams per milliliter in the urine, but was not detected in the blood. No other screened drugs were detected.

AIRCRAFT INFORMATION

FAA information indicated that the airplane was manufactured in 2001 as Beechcraft serial number E-3380, and was equipped with a Continental Motors IO-550 series engine. The airplane was purchased by, and first registered to, the pilot in late 2011.

The airplane was equipped with multiple factory- and post-delivery options. These included factory-installed cabin air conditioning, J.L. Osborne-brand wing tip tanks (20 gallons/side), Precise Flight-brand electric speedbrake system, a JPI-brand EDM-700 engine data monitor, AMSAFE- brand inflatable pilot and copilot dual shoulder harness restraint system, Garmin 430 and 530 nav-com units, and an Aerospace Systems & Technology-brand TKS de-icing system.

All those modifications had been accomplished prior to the pilot's purchase of the airplane. According to those records, the most recent annual inspection was completed on June 1, 2012, when the airplane had a total time (TT) in service of about 893 hours. The records indicated that a "top overhaul" of the engine was completed in April 2004, when the engine had a TT of about 243 hours.

In an interview with the NTSB, one of the pilot's CFIs indicated that the airplane was well-maintained, and that the CFI did not notice any problems or shortcomings with its climb capability, which he pays attention to when flying a new (to him) airplane. NTSB interviews with FLG ground personnel indicated that the airplane was not heavily loaded, and NTSB review of the specific information indicated that for the accident departure, the airplane was likely within its weight and balance envelope.

METEOROLOGICAL INFORMATION

On May 25, the day that the airplane arrived at FLG, the daily maximum recorded temperature of 22 degrees C was reached about noon, and lasted until about 1500 local time.

On May 28, the day of the accident, 1157 FLG automated weather observation included wind from 210 degrees at 17 knots, gusting to 26 knots, visibility 10 miles, clear skies, temperature 18 degrees C, dew point minus 4 degrees C, and an altimeter setting of 29.95 inches of mercury.

COMMUNICATIONS

Partial transcripts of the FLG ATCT ground and local communications surrounding the flight and accident were developed and provided by Serco, the company contracted by the FAA to staff and operate the ATCT.

At 1125:45, the pilot first radioed the ground controller, and advised that he was "ready to taxi," but did not specify any additional intentions. The controller cleared the airplane to runway 21 via the alpha and alpha one taxiways, which the pilot acknowledged. About 5 minutes later the pilot advised the ground controller that he did not realize that there was no run-up area near the runway 21 threshold, and asked for instructions to prevent a conflict with a twin-Cessna behind him. The controller and other pilot rectified the situation by routing the twin-Cessna via another taxiway. At 1136:21, the pilot of the Cessna 172 N3923Q who later witnessed the accident, contacted the controller for taxi clearance to runway 21.

At 1137:20, the Beechcraft pilot first radioed the local controller, and advised that he was "ready for takeoff headed to Tuba City." A few seconds later, the controller cleared the airplane for takeoff, to which the pilot responded "ready for takeoff taking runway two one can you tell me which way for a uh uh downwind departure?" The controller instructed the pilot to make a left downwind, and the pilot acknowledged that communication.

At 1139:24, Cessna 172 N3923Q radioed the local controller that he was ready for takeoff from runway 21, requested a left turnout, and was cleared for same a few seconds later. At 1141:44, the Cessna pilot stated that he was making his left turn, and asked the controller whether the Beechcraft was "okay, he is awful low." At 1141:51, the controller asked if the Beechcraft pilot needed any assistance, and the pilot responded "yah...I'm climbing very slowly and uh I'm climbing very slowly and staying close to the airport." At 1142:15, the Cessna pilot radioed that he did not "understand why he didn't stay over the interstate." At 1142:47, the Cessna pilot radioed that the Beechcraft had crashed and was on fire; the pilot circled the impact location for several minutes in an attempt to guide first responders to the site.

After the accident, the ground controller and the local controller each provided a written statement regarding the flight and accident. Neither statement explicitly cited whether its author actually witnessed the takeoff or climbout. The local controller's statement reported that he was advised of the Beechcraft climb problem by the subsequently-departing Cessna.

AIRPORT INFORMATION

FAA information indicated that the pilot's home airport, MCC, was situated at an elevation of 77 feet above mean sea level.

FAA information indicated that FLG runway 3/21 measured 8,800 by 150 feet, and the airport elevation was listed as 7,140 feet above mean sea level. The runway was served by a single parallel taxiway ("alpha") with 9 access taxiways between the two. There was no dedicated runup area at either runway threshold. A dedicated runup area was situated on taxiway alpha about midway between the ramp and the runway 21 threshold, and the end of the taxiway could also be utilized for that purpose.

The airport was situated in a 2- to 3-mile wide valley that was oriented approximately north-south, with a gentle continuous descent to the south.

Calculations using the meteorological conditions at the time of the accident resulted in an airport pressure altitude of 6,983 feet, and a density altitude of 8,983 feet for FLG.

WRECKAGE AND IMPACT INFORMATION

The accident site was located in the semi-rural neighborhood of Mountainaire, on moderate- to heavily-forested Coconino National Forest (CNF) property. The impact location was about 2.9 nautical miles (nm) from the departure end of FLG runway 21, on a true bearing of 170 degrees (158 magnetic) from that runway location. Impact site elevation was 6,815 feet. Review of topographic data revealed that virtually all of the terrain between the departure end of FLG runway 21 and the impact location was lower than the airport.

The impact site was situated about 1 nm to the east of the southern end of a straight section of a four-lane north-south highway that measured 1.15 nm in length, began about 1.17 nm from the threshold of runway 3, and was at an elevation of about 6,700 feet.

The airplane struck several tall pine trees before it struck the ground. The first tree impact was situated about 40 feet above ground level. The depression angle of the flight path through the trees was about 14 degrees. The distance from the first tree strike to the main wreckage, which primarily consisted of the fuselage from tail to propeller, was 135 feet, on a true heading of 180 degrees.

All major components were accounted for on scene. No evidence consistent with in-flight fire or in-flight structural failure was observed. Propeller and tree damage was consistent with the engine developing power at the time of impact.

The fuselage came to rest upright, on an approximate true heading of 322 degrees. Tree impacts had separated the right wing and the outboard section of the left wing from the airplane. The engine was separated from all four engine mounts, but remained adjacent to the firewall. The propeller remained attached to the engine. The fire consumed or severely damaged a significant portion of the fuselage, including the cockpit instruments and controls, and the cabin and its contents. Due to the fire damage, no useful information was able to be obtained from any cockpit instruments, switches, circuit breakers, or engine controls.

ADDITIONAL INFORMATION

Airframe Examination Details

About 8 feet of the left wing, and the entire right wing, were fracture-separated from the airplane. The left tip tank did not contain any fuel, and did not display any signatures of hydraulic deformation. The right tip tank was breached, did not contain any fuel, and did not reveal any hydraulic deformation. Significant portions of each wing, including both fuel tank bladders were significantly or completely consumed by fire.

Both ailerons remained attached to their respective wings at all mounting hinges, and sustained thermal damage. Aileron cable continuity was established from the right and left control column sprockets to the right and left aileron bellcranks. The aileron trim actuator remained intact and attached to the left wing. The aileron trim actuator extension equated to 2 degrees left tab trailing edge up.

The flaps and flap actuators were all found to be in the flaps-retracted position. Although significantly fire-damaged, the speedbrakes appeared to be in the retracted position at impact.

The horizontal stabilizers remained attached to the aft fuselage and displayed post-impact fire exposure. The left and right elevators, including their balance weights, remained attached to the horizontal stabilizers at the hinges. Elevator control cable continuity was established from the control column to the elevator bellcrank.

The left and right elevator trim surfaces remained attached to their respective elevators at their hinges. The elevator trim actuator extensions equated to approximately 6 degrees tab trailing edge down. Elevator trim cable continuity was confirmed from its cockpit control wheel to the actuators in the empennage.

The vertical stabilizer was fracture-separated from the aft fuselage at its spar roots. A portion of the rudder torque tube, the rudder bellcrank, and fragments of the rudder remained attached to the aft fuselage. The remainder of the fracture-separated rudder, including the rudder balance weight, was found near the aft fuselage. Continuity determination of the rudder control system was limited due to fire damage.

No pre-impact anomalies such as corrosion, wear, or misrouting, were observed on the primary or secondary flight control cables, but thermal and impact damage precluded a complete determination of the cables' pre-accident condition. All cable damage was attributed to impact overload and/or thermal exposure.

Both main landing gear assemblies were found in their retracted positions. The nose landing gear appeared to be in a near-retracted position.

Engine and Fuel System Examination Details

The engine came to rest upright, leaning towards its left side. The throttle, propeller, and mixture control cables remained attached to the throttle quadrant and their respective engine components.

The two magnetos were found properly secured to their mounting pads on the engine. Magneto-to-engine timing testing determined that both magnetos were timed to within 1 de

NTSB Probable Cause

The pilot's inability to maintain a climb after departure in high-density altitude conditions, which resulted in a collision with trees and terrain. Contributing to the accident were the pilot's decision not to track the four-lane highway just beyond the departure runway, which he could have used as an alternate landing site; his premature rotation of the airplane; and degraded engine performance that affected the airplane's climb ability.