Sedona Airport
Aircraft Accident/Incident Report

Sedona, Arizona 86336
Sunday, April 13, 2003 12:30 MST

NTSB Narrative Summary Released at Completion of Accident

The airplane lifted off near the end of the runway, snagged the airport boundary fence, crossed a canyon, and then collided with terrain. Runway 21 was 5,132 feet long, 75 feet wide, and the airport elevation was 4,827 feet. The density altitude was calculated at 6,435 feet. Witnesses noted that the airplane did not seem to accelerate and was rolling very slowly as it passed the midfield point. The engine did not sound like it was producing much power, yet the engine tones stayed steady and the engine sounded smooth. Several of the witnesses noted that the flaps were partially down. The witnesses thought that the pilot would abort the takeoff; however, the airplane continued down the runway and was still on the ground about 80 percent of the way down the runway. Then the pilot rotated it to a takeoff attitude, and broke ground with an extremely nose high attitude. The airplane only attained an altitude of several feet. The landing gear caught the upper strands of the airport boundary fence. The airplane then collided with the far side of a canyon that bordered the airport. The operator had a form that they used for weight and balance and performance. They required pilots to complete the form prior to each flight. The form provided spaces for pilots to record pertinent data, and log computed parameters. Those parameters included takeoff weight, density altitude, runway length, rotation speed, takeoff distance, takeoff distance over a 50-foot obstacle, rate of climb, and landing distance. Calculations for the given takeoff conditions indicated that the airplane should have had a ground roll of 1,900 feet, and would clear a 50-foot obstacle at 2,100 feet. The airplane had an altitude compensating fuel pump installed. The pump would automatically lean or enrich the engine's fuel mixture as the airplane changed altitude. The before takeoff checklist in Section IV of the Pilot Operating Handbook instructed the pilot to takeoff with the mixture in the full rich position. Other instructors from the operator who had flown with the accident instructor indicated that contrary to the instructions in the POH, they all leaned the engine prior to takeoff from high density altitude airports. The spark plugs indicated operation with an excessively lean mixture. Investigators noted no other anomalies with the airframe or engine that would have precluded normal operation.

NTSB Probable Cause Narrative

a partial loss of engine power due to the certified flight instructor's failure to comply with the pilot operating handbook requirements for the mixture setting during takeoff. Also causal was the instructor's inadequate supervision of the flight, failure to monitor the airplane's performance, and failure to initiate an aborted takeoff in a timely way.

Event Information

Type of Event Accident
Event Date 4/13/2003
Event Day of the Week Sunday
Time of Event 1230
Event Time Zone Mountain Standard Time
Event City SEDONA
Event State ARIZONA
Event Country --
Zipcode of the event site 86336
Event Date Year 2003
Event Date Month 4
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 345029N
Event Location Longitude 1114751w
Event Location Airport Sedona
Event Location Nearest Airport ID SEZ
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles 1
Degrees magnetic from airport 205
Airport Elevation 4827
Weather Briefing Completeness Not pertinent
Investigator's weather source Weather Observation Facility
Time of the weather observation 1156 Mountain Standard Time
Direction of event from weather observation facility (degrees) 360
Weather Observation Facility ID FLG
Elevation of weather observation facility 7011
Distance of event from weather observation facility (units?) 18
Time Zone of the weather observation MST
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 14
Dew Point at event time (in degress fahrenheit) -4
Wind Direction (degrees magnetic) 220
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 18
Wind Velocity Indicator --
Wind Gust Indicator Gusting
Wind Gust (knots) 24
Altimeter Setting at event time (in. Hg) 30.14
Density Altitude (feet) 6435
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 3
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 3
Investigating Agency NTSB
NTSB Docket Number (internal use) 20357
NTSB Notification Source FAA
NTSB Notification Date Apr 13 2003 12:00AM
NTSB Notification Time 1300
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Oct 3 2006 2:46PM
User who most recently changed record NTSB\JOHB
Basic weather conditions Visual Meteorological Cond
FAA District Office WP-SDL-FSDO

Aircraft Involved

Aircraft #1

Aircraft Registration Number N323D
NTSB Number LAX03FA135
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? No
Damage Destroyed
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name Beech
Aircraft Model A36
Aircraft Series Identifier --
Aircraft Serial Number E2613
Certified Max Gross Weight 3650
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 6
Number of Engines 1
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection 100 Hour
Date of Last Inspection Mar 12 2003 12:00AM
Airframe hours since last inspection 79.6
Airframe Hours 2249.1
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Mesa Pilot Development, Inc.
Aircraft Owner Street Address 410 N. 44th St., Ste. 700
Aircraft Owner City Phoenix
Aircraft Owner State AZ
Aircraft Owner Country USA
Aircraft Owner Zipcode 85008
Operator is an individual? No
Operator Name --
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City --
Operator State --
Operator Country --
Operator Zip code --
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Instructional
Second Pilot on Board Yes
Departure Point Same as Event Yes
Departure Airport Code SEZ
Departure City SEDONA
Departure State AZ
Departure Country USA
Departure Time 1230
Departure Time Zone MST
Destination Same as Local Flt --
Destination Airport Code IWA
Destination City Phoenix
Destination State AZ
Destination Country USA
Specific Phase of Flight Takeoff - roll/run
Report sent to ICAO? No
Evacuation occurred No
Date of most recent change to record Jul 15 2006 11:35AM
User who most recently changed record COOS
Since inspection or accident Time of Accident
Event Location Runway Number and Location 21
Runway Length 5132
Runway Width 75
Sight Seeing flight No
Air Medical Flight No
Medical Flight --