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Accidents · NTSB WPR19FA115 · Final report

Beech 60 accident near Fullerton, California, April 19, 2019

On April 19, 2019 at about 2:51 am local time, a 1974 Beech 60, registered N65MY, was destroyed in an accident during initial climb near Fullerton, California (Fullerton airport). It was a personal flight under general aviation rules (Part 91). 1 person was killed. The weather was visual conditions (good weather).

The NTSB's probable cause their words, unchanged

The pilot’s use of an unapproved elevator control lock device, and his failure to remove that device and correctly position the elevator before flight, which resulted in a loss of control during takeoff. Contributing to the accident was his failure to perform a preflight inspection and control check, likely in part because of distractions before boarding and his late departure time.

Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.

What the record shows

Date
April 19, 2019 · about 2:51 am local time
Place
Fullerton, California · Fullerton · map
Type
Accident
Injuries
1 person was killed.
Weather
visual conditions (good weather)
Aircraft
Beech 60 B, built 1974 · all 60s on the register
Registration
N65MY · no longer on the register · serial P-314
Damage
Destroyed
Flight
Personal flight · general aviation rules (Part 91)

The NTSB's narrative final · quoted from the NTSB record

The pilot began the takeoff roll in visual meteorological conditions. The airplane was airborne about 1,300 ft down the runway, which was about 75% of the normal ground roll distance for the airplane’s weight and the takeoff environment. About 2 seconds after rotation, the airplane rolled left. Three seconds later, the airplane had reached an altitude of about 80 ft above ground level and was in a 90° left bank. The nose then dropped as the airplane rolled inverted and struck the ground in a right-wing-low, nose-down attitude. The airplane was destroyed. Postaccident examination did not reveal any anomalies with the airframe or engines that would have precluded normal operation. The landing gear, flap, and trim positions were appropriate for takeoff and flight control continuity was confirmed. The symmetry of damage between both propeller assemblies indicated that both engines were producing equal and high amounts of power at impact. The autopsy revealed no natural disease was present that could pose a significant hazard to flight safety. Review of surveillance video footage from before the accident revealed that the elevator was in the almost full nose-up (or trailing edge up) position during the taxi and the beginning of the takeoff roll. Surveillance footage also showed that the pilot did not perform a preflight inspection of the airplane or control check before the accident flight. According to the pilot’s friend who was also in the hangar, as the accident pilot was pushing the airplane back into his hangar on the night before the accident, he manipulated and locked the elevator in the trailing edge up position to clear an obstacle in the hangar. However, no evidence of an installed elevator control lock was found in the cabin after the accident. The loss of control during takeoff was likely due to the pilot’s use of an unapproved elevator control lock device. Despite video evidence of the elevator locked in the trailing edge up position before the accident, an examination revealed no evidence of an installed control lock in the cabin. Therefore, during the night before the accident, the pilot likely placed an unapproved object between the elevator balance weight and the trailing edge of the horizontal stabilizer to lock the elevator in the trailing edge up position. The loss of control was also due to the pilot’s failure to correctly position the elevator before takeoff. The pilot’s friend at the hangar also reported that the pilot was running about one hour late; the night before, he was trying to troubleshoot an electrical issue in the airplane that caused a circuit breaker to keep tripping, which may have become a distraction to the pilot. The pilot had the opportunity to detect his error in not freeing the elevator both before boarding the airplane and again while in the airplane, either via a control check or detecting an anomalous aft position of the yoke. The pilot directed his attention to the arrival of a motorbike in the hangar alley shortly after he pulled the airplane out of the hangar, which likely distracted the pilot and further delayed his departure. He did not conduct a preflight inspection of the airplane or control check before the accident flight, due either to distraction or time pressure.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

The factual record from the NTSB's investigation tables, in plain English

What happened, in order

  1. Loss of control in flight during initial climb defining event
  2. Miscellaneous/other during takeoff
  3. Aircraft inspection event during prior to flight

The NTSB's findings

  • Personnel issues › Action/decision › Action › Forgotten action/omission › Pilot
  • Aircraft › Aircraft handling/service › Parking/securing › Parking/storage › Incorrect use/operation
  • Personnel issues › Task performance › Use of equip/info › Use of checklist › Pilot
  • Personnel issues › Psychological › Attention/monitoring › Attention › Pilot
  • Personnel issues › Task performance › Inspection › Preflight inspection › Pilot
  • Aircraft › Aircraft oper/perf/capability › Performance/control parameters › Pitch control › Attain/maintain not possible

Pilot

  • Certificate: private
  • Ratings: multi-engine land; instrument: airplane
  • Flight time: 380.5 hours in all; 87 in this make and model; 38.3 in the last 90 days; 26.8 in the last 30 days
  • Last flight review: March 30, 2019
  • Medical certificate: Class 3 (with waivers/limitations)
  • Seat: left
  • Injury: fatal

The aircraft

  • Airframe total time: 5,419.3 hours
  • Last inspection: annual inspection, December 26, 2018; 49.5 hours since
  • Maximum gross weight: 6,965 lb
  • Seats: 6
  • Landing gear: retractable
  • Engine 1: Lycoming TIO-541-E1C4 (piston); 0 hours total
  • Engine 2: Lycoming TIO-541-E1C4 (piston); 0 hours total
  • Fire on the ground

The flight

  • Departed from: FUL Fullerton CA at 1:50 am
  • Destination: HCR Heber UT
  • Flight plan: IFR
  • Runway 24, 3,121 ft by 75 ft

Weather at the time

  • Light: dusk
  • Wind: at 6 knots
  • Visibility: 10 statute miles
  • Sky: clear
  • Temperature: 66°F (19°C), dew point 46°F (8°C)
  • Altimeter: 30.10 inHg
  • Observation at 7:53 pm from KFUL

Injuries

FatalSeriousMinorNone
Flight crew1

Documents from the investigation the NTSB's docket: the evidence folder behind the report

28 documents, released by the NTSB on June 23, 2021. View them here, or download them; the NTSB redacts some personal details before release, and this site shows the NTSB's own titles rather than its file names.

#DocumentWhat it is
1 Electronic Devices Specialist's Factual Report PDF, 9 pages View Download
2 Attachment 1 to Electronic Devices Specialist's Factual Report data file Download
3 Attachment 2 to Electronic Devices Specialist's Factual Report data file Download
4 Tower Audio - Local Control Position audio View Download
5 Witness Statements PDF, 12 pages View Download
6 NTSB Airframe and Engine Examination Report PDF, 20 pages View Download
7 Propeller Assembly Comparison PDF, 3 pages View Download
8 Normal Takeoff Performance Chart PDF, 1 page View Download
9 Maintenance Logbook Excerpts PDF, 10 pages View Download
10 Fuel Logs PDF, 1 page View Download
11 Control Lock and Elevator Examples PDF, 3 pages View Download
12 Type Certificate Data Sheet Number A12CE PDF, 5 pages View Download
13 Statement of Party Representatives to NTSB Investigation PDF, 25 pages View Download
14 Release of Aircraft Wreckage, NTSB Form 6120.15 PDF, 1 page View Download
15 Toxicological Report PDF, 1 page View Download
16 April 11 Video of Runup - Midfield Facing Northeast. (Video Timestamp 07.07 Slow). Provided by the City of Fullerton. video View Download
17 April 11 Video of Takeoff - Midfield Facing North. (Video Timestamp 07.07 Slow). Provided by the City of Fullerton. video View Download
18 April 11 Video of Beginning of Takeoff Roll - West End Facing North. (Video Timestamp 07.07 Slow). Provided by the City of Fullerton. video View Download
19 April 11 Video of Rotation - Midfield Facing Northeast. (Video Timestamp 07.07 Slow). Provided by the City of Fullerton. video View Download
20 April 11 Video of Departure from Hangar - Facing West. (Video Timestamp 07.07 Slow). Provided by the City of Fullerton. video View Download
21 April 17 Video of Airplane Returning to Hangar After Getting Fuel - Facing West. (Video Timestamp 07.07 Slow). Provided by the City of Fullerton. video View Download
22 April 18 Video of Airplane Departing Hangar for Accident Flight - Facing West. (Video Timestamp, 07.07 Slow). Provided by the City of Fullerton. video View Download
23 April 18 Video of Runup - Midfield Facing Northeast. (Video Timestamp, 07.07 Slow). Provided by the City of Fullerton. video View Download
24 April 18 Video of Takeoff and Left Roll - Midfield Facing South. (Video Timestamp, 07.07 Slow). Provided by the City of Fullerton. video View Download
25 April 18 Video of Takeoff and Impact - Midfield Facing North. (Video Timestamp, 07.07 Slow). Provided by the City of Fullerton. video View Download
26 April 18 Video of Airplane Departing from Hangar - Facing West. (Video Timestamp, 07.07 Slow). Provided by the City of Fullerton. video View Download
27 Elevator Position Comparison Between April 11 and April 18 Video of Airplane Departing Hangar - Facing West. (Video Timestamp, 07.07 Slow). Provided by the City of Fullerton, Composite Created by Text video View Download
28 Elevator Position Comparison Between April 11 and April 18 Video of Airplane in Runup Area - Facing Northeast. (Video Timestamp, 07.07 Slow). Provided by the City of Fullerton, Composite Created by Te video View Download

The same docket at the NTSB · documents without a copy here are fetched from the NTSB when you open them.

Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.