NTSB Factual Report

On April 5, 2004, at 0820 Pacific daylight time, a Beech V35, N7923M, collided with terrain during takeoff from the Elko Regional Airport, Elko, Nevada. The pilot was operating the airplane under the provisions of 14 CFR Part 91. The airline transport pilot and one passenger sustained serious injuries; the airplane was destroyed. The flight was originating at the time, with an ultimate destination of the Monmouth Executive Airport, Belmar/Farmingdale, New Jersey. Visual meteorological conditions prevailed, and no flight plan had been filed.

Airport personnel stated that the pilot and the passenger arrived the previous day, approximately 1300. They refueled the airplane with 37.5 gallons of fuel. They retired to their hotel, and returned to the airport at 0800 the morning of the accident.

A certified flight instructor (CFI) was meeting with one of his students the day the pilot arrived. The accident pilot began asking the CFI a series of questions about high-altitude operations, mountainous operations, and leaning the mixture. The accident pilot was also concerned with the weather. The CFI answered the accident pilot's questions. The accident pilot seemed nervous about the upcoming flight. The CFI's assessment of the pilot was that he was a 100-hour private pilot that had not flown recently.

A witness reported that the airplane was departing runway 5. The airplane rotated approximately 5,000 feet down the runway.

An additional witness, who holds an Airline Transport Pilot certificate, reported that after liftoff, the airplane was wallowing about 12 feet above ground level (agl) as it flew down the runway. The engine did not sound like it was producing full power. The airplane cleared the airport fence by 4 feet, and then touched down about 80 yards from the fence. The airplane hit objects, and a post-impact fire consumed the airplane.

A receptionist at a local fixed base operator reported that the pilot and his passenger landed around 1300 from California. As the receptionist spoke with the passenger, the passenger remarked how she considered taking a commercial flight but was happy seeing the country in the smaller airplane. The pilot was concerned with flying around the mountain areas and desired to fly to Scottsbluff, Nebraska. The receptionist further reported that one of the CIF’s came into the office to do an introductory flight. The accident pilot began asking the CFI questions about flying in the mountains. The passenger said they were going to take the southern route; however, the weather was poor.

The morning of the accident the pilot was instructed by the air traffic control tower (ATCT) to taxi to runway 30. The airplane was observed across the runway hold line and the controller advised the pilot. No other aircraft were involved and there was no loss of separation. The pilot requested another runway for departure and was taxied to runway 5 per his request. During the pilot's takeoff roll, he queried the controller as to any noise abatement procedures in the area.

According to the Airport Facility Directory (AFD), Southwest, runway 5 is 7,214 feet in length. The field elevation is 5,140 feet mean sea level (msl).

A Federal Aviation Administration (FAA) coordinator responded to the accident site. The coordinator reported that the mixture control arm was set approximately 3 inches out from its full rich stop. The baggage contained in the airplane was minimal.

The pilot reported 30,075 hours total flight time, with 350 hours flight time in make/model, on his most recent insurance application.

A review of the pilot's most recent logbook indicated limited mountain flying experience. The logbook began on July 1, 2001. Over that time period, the pilot flew to three airports with elevations greater than 2,000 feet msl: El Paso, Texas (3,958 fee msl); Bozeman, Montana (4,471 feet msl); and the accident location of Elko (5,140 feet msl). The airplane was based in New Jersey and the pilot made regular trips to Carslbad, California. Per the routing in the logbook, his flight route would normally take him over the southern part of the United States.

The engine was shipped to the Teledyne Continental factory, Mobile, Alabama, for examination and test run. The testing began on October 28, 2004, with the National Transporation Safety Board investigator-in-charge (IIC), a Beech Raytheon representative, and a Teledyne Continental representative in attendance. The spark plugs were removed and examined. Their coloration was consistent with a lean operation when compared to a Champion Check-A-Plug chart.

To facilitate the test run, the following parts were removed from the engine: propeller governor; vacuum pump; alternator; and the starter (broken off during impact sequence). The following parts were replaced on the engine: left front mount leg; right rear mount leg; starter; and the inlet, return, and outlet fuel lines on the fuel control unit (thermally damaged). The ignition harness sustained thermal damage in the post-accident fire; however, the engine was test run using the original harness. The engine was placed in a test cell and test run. During the test run, the magnetos were checked with the engine producing 2,100 rpm. The left magneto had an rpm drop of 756; the right magneto had an rpm drop of 208. The engine produced 2,550 rpm during the test run. The standard operating rpm is 2,700 rpm. According to the manufacturer, the decrease of 150 rpm from standard operating rpm would not have precluded the engine from producing the power needed for takeoff.

According to the Pilot's Handbook of Aeronautical Knowledge (AC 61-23C), operation with an excessively lean mixture, i.e., too little fuel in terms of the weight of air, will result in rough engine operation, detonation, overheating, and [or] loss of power.

A Safety Board meteorologist prepared a series of radar summary charts for the periods before and after the accident site. The charts indicated that a weather cells were present over portions of Arizona, New Mexico, and Texas.

NTSB Probable Cause

the pilot's improper mixture leaning technique and failure to attain an adequate airspeed during takeoff, which resulted in a stall/mush.