Bisbee Airport
Aircraft Accident/Incident Report

Bisbee, Arizona 85603
Monday, September 19, 2005 15:45 MST

NTSB Narrative Summary Released at Completion of Accident

The airplane settled back to the ground during the takeoff initial climb and collided with bushes and desert terrain off the end of the runway, bending the right wing and aft carry-though spars. The airport was at an elevation of 4,780 feet mean sea level (msl) and the density altitude was 6,692 feet msl. During his leaning of the mixture, the pilot set the rpm at 1,800, leaned the mixture for an increase in rpm, then richened the mixture by one full turn, all in accordance with instructions given him during his check-out in the rental airplane by a flight instructor. The pilot completed his pre-takeoff checklist, made a traffic advisory, and positioned the airplane for takeoff. He held the brakes and applied full throttle. As the rpm came up to 2,600 rpm, the engine sounded normal, the brakes were released, and he began the takeoff roll. During the takeoff ground roll, a significantly greater distance was required to develop airspeed than the pilot expected; however, he thought this to be the result of the airport elevation and the outside air temperature. The pilot operating handbook (POH) performance charts showed that a ground roll of 2,100 feet should have been required to achieve takeoff over a 50-foot obstacle. The airplane reached 65 knots approximately 2/3 down the 5,929-foot-long runway and slight elevator back pressure was applied. The airplane lifted off and back pressure was eased to remain in ground effect and continue airspeed acceleration. However, the airplane did not accelerate, but instead settled back to the ground. The airplane touched down just off the end of the runway and came to a stop approximately 20 feet from the airport perimeter fence. The day prior to the accident, the pilot was checked out in the airplane. Following the check-out flight, he asked the certified flight instructor (CFI) the proper leaning procedures for the airplane. He was told to lean the mixture at run-up (1,800 rpm) using engine rpm, and then richen it one full turn at field elevations below 5,000 feet msl, and to lean the mixture at full power using the exhaust gas temperature gauge at field elevations above 5,000 feet msl. The POH states that the engine should be leaned using 2,600 rpm using the combined manifold and fuel flow indicator gauge. This gauge shows fuel flow in gallons per hour and is marked with a green arc to indicate normal fuel flow operating parameters for different power settings. The takeoff optimum fuel performance range is covered by green sectors and the high side of each green sector represents the appropriate fuel setting required to obtain maximum power when operating at full throttle and 2,600 rpm. A Federal Aviation Administration inspector test-ran the engine following the accident and no operational anomalies were noted.

NTSB Probable Cause Narrative

the pilot's failure to lean the mixture in accordance with the pilot operating handbook specified procedures, which resulted in a power deficiency, a degraded climb capability, and the inability to attain/maintain an adequate airspeed that led to a stall/mush condition while departing in high density altitude conditions. The pilot's failure to abort the takeoff when an excessive takeoff ground roll became apparent was also causal. Also causal, was the certified flight instructor's failure to provide the proper leaning procedures during a preflight briefing.

Event Information

Type of Event Accident
Event Date 9/19/2005
Event Day of the Week Monday
Time of Event 1545
Event Time Zone Mountain Standard Time
Event City Bisbee
Event State ARIZONA
Event Country --
Zipcode of the event site 85603
Event Date Year 2005
Event Date Month 9
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 312150N
Event Location Longitude 1095259W
Event Location Airport Bisbee
Event Location Nearest Airport ID P04
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles 0.24
Degrees magnetic from airport --
Airport Elevation 4780
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1556 Mountain Standard Time
Direction of event from weather observation facility (degrees) 66
Weather Observation Facility ID DUG
Elevation of weather observation facility 4154
Distance of event from weather observation facility (units?) 15
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) 23
Dew Point at event time (in degress fahrenheit) 16
Wind Direction (degrees magnetic) 360
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 11
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.21
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None 3
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 20187
NTSB Notification Source FAA
NTSB Notification Date Sep 19 2005 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Aug 29 2006 3:49PM
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 N5757D
NTSB Number LAX05LA305
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed VFR
Flight plan Was Activated? No
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Beech
Aircraft Model 35-C33
Aircraft Series Identifier --
Aircraft Serial Number CD-1092
Certified Max Gross Weight 3050
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 4
Number of Engines 1
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection 100 Hour
Date of Last Inspection Jun 1 2005 12:00AM
Airframe hours since last inspection 65
Airframe Hours 5325
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Morwalk Leasing
Aircraft Owner Street Address 1675 Ryan Road
Aircraft Owner City Chandler
Aircraft Owner State AZ
Aircraft Owner Country USA
Aircraft Owner Zipcode 85249
Operator is an individual? No
Operator Name Chandler Air Service
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 1675 E. Ryan Rd
Operator City Chandler
Operator State AZ
Operator Country USA
Operator Zip code 85249
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) Personal
Second Pilot on Board No
Departure Point Same as Event Yes
Departure Airport Code P04
Departure City Bisbee
Departure State AZ
Departure Country USA
Departure Time 1545
Departure Time Zone MST
Destination Same as Local Flt --
Destination Airport Code CHD
Destination City Chandler
Destination State AZ
Destination Country USA
Specific Phase of Flight Takeoff
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jun 12 2006 6:33PM
User who most recently changed record COOS
Since inspection or accident Time of Accident
Event Location Runway Number and Location 17
Runway Length 5929
Runway Width 60
Sight Seeing flight No
Air Medical Flight No
Medical Flight --