NTSB CAROL · Event
Event LAX01LA095
Registry · N3191A
FAA Aircraft Registry record.
Make / Model
BEECH A36
Year of manufacture
1999 · 2 years old at event
Engine
CONT MOTOR IO-550 SERIES (300 hp)
Seats / Engines
6 seats · 1 engine
Last airworthiness date
19991218
ADS-B equipped
Yes — Mode-S A36ABC
Registrant of record
PASTERNAK ELIEZER TRUSTEE
Source: FAA Aircraft Registry (releasable master file).
Aircraft involved
Probable cause & findings
The pilot-in-command's delayed decision to go-around and his failure to maintain sufficient airspeed during the attempted go-around. His non-verification of the flap setting contributed to the accident.
Factual narrative
On February 9, 2001, at 1412 hours Pacific standard time, a Beech A36, N3191A, sustained substantial damage when the it struck the ground during an attempted go-around at the Palo Alto, California, airport. The private pilot operated the airplane under the provisions of 14 CFR Part 91, and was not injured. The personal local flight departed approximately 1400. Visual meteorological conditions prevailed, and no flight plan had been filed. When interviewed by National Transportation Safety Board investigators, the pilot stated that his intention was to practice takeoffs and landings. He extended downwind for spacing on a slower airplane, and recalls selecting approach flaps but does not recall checking the position of the flaps. The final approach was stable at 80 knots but when he was about 10 feet off the ground he sensed the airplane was sinking faster than normal and elected to go around. He added power but did not feel the engine respond. The airplane veered left and the left wing struck the ground, the left gear was sheared off, and the propeller was torn off the engine. The pilot said that after examining the airplane the flaps appeared to be up. The airplane, equipped with a Rolls-Royce Model 250-B17F/2 Turboprop engine, had been purchased in August 2000. The pilot had received dual instruction in the airplane but his insurance carrier required he hold an instrument rating prior to acting as pilot-in-command. His instrument rating was received February 7, 2001. The pilot had received 107.9 hours of dual instruction in the airplane and the accident flight was his first solo flight in type. A representative of Rolls-Royce Corporation participated in the investigation. No engine discrepancies were noted. However, the beta valve tie rod was displaced from the rod end connector. No signs of safety wire or damaged threads on the tie rod or rod end were noted. Upon removing the engine oil filter housing, no filter was found. It was noted that the compressor received leading edge damage to all first stage blades. Also, fuel control and fuel nozzle tests indicated no signs of malfunction. A representative of Hartzell Propeller, Inc., the manufacturer of the propeller, participated in the investigation. The propeller blades were found in a high pitch/feather position. The piston had a clear impact mark, about 25 degrees blade angle. The representative explained that this is a realistic blade angle for a "power on" impact. The representative concluded that this mark indicated that the piston was at 25 degrees, or lower, blade angle prior to impact because the blades were driven to feather as a result of impact damage. He also found that the engine-mounted beta valve link arm was disconnected and the lockwire was missing from the jam nut. A pilot taxiing on a taxiway parallel to the runway witnessed the accident. He stated that he saw the airplane flare approximately one wingspan's height above the runway and begin drifting to the left. The airplane continued drifting to the left in a very nose-high attitude. It drifted over the taxiway about 40 feet agl. The drift stopped and the right wing dropped. The right wing hit the grass between the taxiway and the runway and the airplane spun around and stopped on the runway. The airplane's right wing struck the ground and the airplane came to rest on the runway following a loss of control on an attempted go-around. The pilot had received 107.9 hours of dual instruction and was making his first solo flight in the airplane. The purpose of the flight was to practice takeoffs and landings. The pilot selected approach flaps on downwind but never checked their position. On short final, the pilot sensed his descent rate was too great and attempted a go-around. The airplane drifted towards the left and then rolled right continuing to descend until it struck the ground. Postcrash examination of the engine and propeller revealed impact damage that was consistent with the propeller having contacted the ground in a high airplane pitch attitude, and a propeller blade angle consistent with a "power on" condition. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_2001_LAX01LA095.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (loss of control, go-around). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Embry-Riddle Scholarly Commons 2025 · Journal article (JAAER)
A Scoping Review of Aviation Loss of Control Inflight Research
Loss of control – inflight (LOC-I) contributes to aircraft accidents at unacceptably high rates. Significant industry efforts and research have aimed to improve LOC-I prevention, detection, and recove…
- NASA NTRS 2025 · Conference Paper
A Training Study to Improve Monitoring During A Go-Around
As part of an FAA program to improve go-around (GA) safety, we were asked to determine if we could improve the performance of the Pilot Monitoring (PM) during a GA maneuver.
- Flight Safety Foundation 2024 · FSF / AeroSafety World
Go-Around Safety Forum Findings
Foundation Go-Around Safety Forum technical findings — examines why pilots fail to execute go-arounds when criteria are met (stabilized approach gate not met, energy state out of envelope, traffic con…
- SKYbrary (Eurocontrol) 2024 · SKYbrary article
Loss of Control In-Flight (LOC-I) — SKYbrary Knowledge Base
SKYbrary comprehensive knowledge-base entry on Loss of Control In-Flight — definitions, contributing factors, accident case studies (Air France 447, Colgan 3407), and prevention strategies.
- Embry-Riddle Scholarly Commons 2023 · Conference paper
Utilizing Deep Learning to Predict Unstabilized Approaches for General Aviation Aircraft
Unstabilized approaches pose a major hazard for general aviation aircraft. In the period from 2009 to 2019, 3,257 general aviation accidents occurred during the landing phase of flight in which loss o…
- NTSB Aircraft Accident Reports 2022 · Accident report
Loss of Control on Takeoff in Icing Conditions — Citation 560XL
Cessna Citation 560XL fatal takeoff icing accident, March 2018. Investigation of a Citation 560XL loss-of-control takeoff accident in icing conditions.
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