NTSB Factual Report

HISTORY OF FLIGHT

On June 12, 2015, about 0700 central daylight time, a Beech A-36 airplane, N3193W, was destroyed by impact forces and a post impact fire following a loss of control during initial climb after takeoff from a private airstrip near Huggins, Missouri. The pilot and three passengers received fatal injuries. One passenger received serious injuries. The aircraft was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight, which was not on a flight plan. The flight was originating at the time of the accident and the final destination was the Provo Municipal Airport, Provo, Utah.

The brother of the pilot was a witness to the accident. He stated that he saw the airplane taxi to the north end of the 2,000 foot long grass runway where it turned around for a takeoff to the south. He said that the airplane lifted off and then began a right turn toward an opening in the tree line at the departure end of the runway. The airplane then pitched up abruptly, rolled to the left and dove into the ground.

PERSONNEL INFORMATION

The pilot held a private pilot certificate with a single-engine land airplane rating. He was issued a third-class airman medical certificate, with no restrictions, on November 12, 2014. The pilot's logbook was not available for review during the investigations.

AIRCRAFT INFORMATION

The accident airplane was a Beechcraft model A-36 "Bonanza", serial number E-555, manufactured in 1974. It was a six-place, low wing, single engine airplane, with a tricycle landing gear configuration. The airplane was issued an FAA normal category standard airworthiness certificate on April 9, 1974. The airplane was powered by a 285-horsepower Continental Motors IO-520-BA, six-cylinder, reciprocating engine, serial number 280725-R.

The airframe, engine, and propeller logbooks were not recovered during the investigation; however the maintenance shop that performed the most recent annual inspection provided copies of the maintenance endorsements. That annual inspection was completed on June 3, 2014.

According to registration records, the pilot purchased the airplane in April 14, 2005.

METEOROLOGICAL INFORMATION

At 0658, the weather conditions at the Waynesville-St. Robert Regional Airport-Forney Field, Ft. Leonard Wood, Missouri, about 24 miles north of the accident site were: wind from 190 degrees at 7 knots; wind direction variable from 160 degrees to 230 degrees; visibility 10 statute miles; sky condition clear; temperature 25 degrees Celsius; dew point 23 degrees Celsius; altimeter setting 29.85 inches of mercury.

AIRPORT INFORMATION

The airport used during the accident was a privately owned airstrip having a turf runway that was about 2,000 ft long by 60 ft wide. The airstrip was owned by the pilot's father. The runway was oriented in a north-south direction. To the north of the runway there were no obstructions and the terrain sloped downward away from the runway. At the south end of the runway was a two-story house and trees measuring about 70 ft in height. The runway had an upward slope in the south direction. About 180 feet west of the south end of the runway was a clearing in the trees that was used as a taxiway leading to the runway. The clearing was about 180 feet wide.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest about 100 feet west of the south end of the private 2,000 foot long grass runway. The runway in the takeoff direction, south, had a slight uphill slope and trees about 70 ft tall at the departure end. The north end of the runway had no obstructions and the ground sloped downward into a valley after the runway end. The airplane came to rest in an inverted position with the nose of the airplane pointing approximately 150 degrees magnetic. The entire cabin section of the airplane and the majority of the left wing were consumed by a postimpact fire. The right wing was predominately intact with fire damage to the inboard end and crush damage along the length of the wing. The lower fuselage skin had separated at the aft edge exposing the internal wing structure. The majority of the wreckage was contained within the immediate vicinity of the main wreckage. The propeller was found with the initial impact crater with all three blades still attached to the hub. All three blades exhibited varying amounts of leading edge gouging and chordwise scratching. The crankshaft flange remained attached to the propeller hub, but had separated from the remainder of the engine crankshaft. The position of the propeller indicated a near vertical impact. Impact scars for both wings were also observed. Based on the takeoff direction, the airplane had rolled to an inverted attitude prior to impact.

The tail surfaces remained intact with little damage. The damage consisted to bending and crumpling of the top of the vertical stabilizer. The rudder and elevator control cables were intact from the tail surfaces to their forward mounting positions. Due to the extensive fire damage the aluminum control components within the cabin had melted. The elevator trim cable was intact except for a separated link at the sprocket in the cockpit. The aileron balance cable was intact from the right aileron bellcrank to the left attachment point of the cable. The left bellcrank was consumed by the fire. The left aileron control cable was intact from connection point at the aileron bellcrank to the other connection point within the cabin. The right aileron control cable was intact from the right aileron bellcrank to the cabin area where the opposite end was broken. The remaining portion of the cable was not located. The broken end exhibited signatures consistent with overload failure. Both flap control actuators were melted and consumed by fire. Determination of the flap position was not possible.

The airplanes engine had broken loose from its mounts during the impact sequence. External examination of the engine revealed no evidence of a failure. The engine was retained for a future teardown examination.

Examination of the engine was conducted at the manufacturer's facility under the supervision of the NTSB Investigator in Charge. The engine displayed a significant amount of damage consistent with impact damage and thermal damage. The thermal damage was concentrated to the rear portion of the engine and the impact damage was concentrated to the forward portion of the engine. The propeller flange had broken free from the rest of the crankshaft and there was a small portion of the crankcase that had broken free from the rest of the crankcase; the damage was consistent with impact damage. All six cylinders remained attached to their cylinder bays and displayed varying degrees of thermal and impact damage.

The induction system displayed a significant amount of thermal damage signatures and impact damage signatures. The thermal damage was concentrated to the rear portions of the induction system. The exhaust system displayed impact damage signatures in the forms of bending, crushing, and tearing.

Both of the magnetos remained attached to their mounting points and displayed thermal damage signatures. The ignition harness remained attached to both of the magnetos and to the spark plugs. The ignition harness displayed a significant amount of thermal damage on all of the ignition leads and there were some impact damage signatures. All of the spark plugs remained installed in their cylinders and displayed varying degrees of impact and thermal damage.

The fuel pump remained attached to its installation point and displayed thermal damage signatures. The throttle and fuel metering assembly had broken free from the induction system and displayed thermal and impact damage signatures. The fuel manifold valve remained attached to its installation point and displayed thermal damage signatures. All of the fuel nozzles remained installed in their cylinders and displayed varying degrees of thermal and impact damage.

The engine was disassembled and examination of the internal components did not reveal any anomalies that would have precluded normal operation.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy of the pilot was performed on behalf the Texas County Coroner's Office, by Southwest Missouri Forensics, Nixa, Missouri, on June 15, 2015. The pilot's death was attributed to injuries received in the accident.

Toxicology testing was performed by the FAA Civil Aerospace Medical Institute. Testing results were negative for all substances in the screening profile.

ADDITIONAL INFORMATION

A handheld GPS receiver was recovered from the accident site and its recorded data downloaded. The downloaded data included 15 data points associated with the accident date, recorded about 7 seconds apart. The data confirmed the brother's report that the airplane taxied to the extreme north end of the runway and then turned for a takeoff to the south. The airplane lifted off about 900 feet from the from the north end of the runway and began turning to the right (west) of the runway centerline. The GPS recorded ground speed at liftoff was about 44 knots. The airplane accelerated to a maximum GPS recorded ground speed of 50 knots before its ground speed decreased to 44 knots at the end of the recorded data. The last recorded data point was about 270 ft north of the wreckage location.

Based on the last recorded GPS data point and the reported wind, the airplane's airspeed was estimated to be 51 knots at the last recorded data point. The airplane's fuel load was not known and an accurate estimation of the takeoff weight could not be determined. Additionally, the Airplane Flight Manual did not list power on stall speeds; however it listed power off, flaps up, zero bank stall speeds ranging from 57 kts to 65 kts, dependent on weight. The flaps down stall speeds ranged from 53 kts to 58 kts; however, the manual required flaps to be retracted for takeoff.

NTSB Probable Cause

The pilot's failure to maintain adequate airspeed and his exceedance of the airplane's critical angle-of-attack, which resulted in an aerodynamic stall and loss of control.