# NTSB CEN17LA029: Beech 100, N411HA, Jeffersonville, IN, October 30, 2016

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: October 30, 2016, 12:35 local (16:35 UTC)
- Place: Jeffersonville, IN
- Coordinates: 38.355278, -85.738052
- Nearby events: https://openairdocs.org/map.md?lat=38.3553&lon=-85.7381&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Defining event: [Takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300)
- Highest injury: No injuries
- Injuries: 10 uninjured
- Status: Completed, report January 18, 2017
- Report: Approved by Office Director
- NTSB office: Central Region
- Parties: FAA Indianapolis FSDO
- NTSB case key (mKey): 94314
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN17LA029
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94314/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94314
- Page: https://openairdocs.org/ntsb/CEN17LA029

## Probable cause

The pilot’s inadequate preflight planning, his decision to take off knowing the airplane was over its gross takeoff weight, and his failure to abort the takeoff after he realized that the airplane was not accelerating as expected, which resulted in a runway excursion.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Aircraft capability: takeoff distance](https://openairdocs.org/ntsb-findings/01061025): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Beech 100, 1 case](https://openairdocs.org/ntsb-findings/01061025/cases.md?model=1152916), [All aircraft, 67 cases](https://openairdocs.org/ntsb-findings/01061025/cases.md)
- [Planning/preparation: weight/balance calculations](https://openairdocs.org/ntsb-findings/02061015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech 100, 1 case](https://openairdocs.org/ntsb-findings/02061015/cases.md?model=1152916), [All aircraft, 110 cases](https://openairdocs.org/ntsb-findings/02061015/cases.md)
- [Planning/preparation: performance calculations](https://openairdocs.org/ntsb-findings/02061010): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech 100, 1 case](https://openairdocs.org/ntsb-findings/02061010/cases.md?model=1152916), [All aircraft, 114 cases](https://openairdocs.org/ntsb-findings/02061010/cases.md)
- [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech 100, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=1152916), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md)
- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech 100, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1152916), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech 100, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=1152916), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md)
- [Aircraft capability: maximum weight](https://openairdocs.org/ntsb-findings/01061035): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Beech 100, 1 case](https://openairdocs.org/ntsb-findings/01061035/cases.md?model=1152916), [All aircraft, 152 cases](https://openairdocs.org/ntsb-findings/01061035/cases.md)
- [Training: initial training](https://openairdocs.org/ntsb-findings/04031010): Organizational issues › Support/oversight/monitoring · Operator; cases with it: [Beech 100, 1 case](https://openairdocs.org/ntsb-findings/04031010/cases.md?model=1152916), [All aircraft, 15 cases](https://openairdocs.org/ntsb-findings/04031010/cases.md)
- [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Copilot; cases with it: [Beech 100, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=1152916), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Beech 100, 1 case](https://openairdocs.org/ntsb-events/300/sequence.md?model=1152916), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md)
- [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech 100, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=1152916), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)
- [Takeoff: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [Beech 100, 1 case](https://openairdocs.org/ntsb-events/094/sequence.md?model=1152916), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md)

## Analysis

The airline transport pilot, who was the pilot flying, and commercial pilot, who was the pilot not flying and was acting as a safety pilot and was not expected to know the airplane's systems, limitations, or characteristics, were preparing to depart for a personal flight with eight passengers on board. When the pilot arrived at the airport, he determined that the airplane had 900 lbs of fuel onboard. He instructed the lineman to fuel the airplane with 211 gallons of fuel (1,413.7 lbs) for a fuel total of 2,313.7 lbs. The pilot reported that he was aware that the total weight of the eight passengers, their bags, and the fuel caused the airplane to be overweight but that he did not complete a weight and balance form or determine the expected takeoff performance before the flight. He informed the other pilot that the flight would be heavy, but he did not tell him how much the airplane exceeded the airplane's maximum gross takeoff weight. After the accident, the pilot determined that the airplane was 623 lbs over the maximum gross takeoff weight. The pilot reported that the airplane's flight controls and engines were operating normally during the pretakeoff check and that the elevator pitch trim was positioned in the "green" range. The pilot taxied the airplane onto the runway and applied the brakes and increased the throttles to takeoff power before releasing the brakes for the takeoff roll. However, he did not confirm the power settings that he applied when he advanced the throttles. The airplane did not accelerate as quickly as the pilot expected during the takeoff roll. When the airplane was about halfway down the runway, the airspeed was 80 kts, so the pilot continued the takeoff roll, but the airplane was still not accelerating as expected. He stated that he heard the other pilot say "redline," so he decreased the power. At this point, the airplane had reached the last third of the runway, and the pilot pulled back on the control yoke to lift the airplane off the runway, but the stall warning sounded. He lowered the nose, but the airplane was near the end of the runway. He added that he did not get "on" the brakes or put the propellers into reverse pitch and that the airplane then departed the runway. The pilot veered the airplane right to avoid the instrument landing system antenna, which was 500 ft from the end of the 5,500-ft-long runway, but the left wing struck the antenna, the left main landing gear and nose gear collapsed, and both propellers contacted the ground. The airplane then skidded left before stopping about 680 ft from the end of the runway. The pilot reported that the airplane did not have any preaccident mechanical malfunctions or failures. The evidence indicates that the pilot decided to depart knowing that the airplane was over its maximum gross takeoff weight and without determining the expected takeoff performance. During the takeoff roll, he did not check his engine instruments to determine if he had applied full takeoffpower, although the acceleration may have been sluggish because of the excess weight onboard. The other pilot was not trained on the airplane and was not able to provide the pilot timely performance information during the takeoff. Neither the pilot nor the other pilot called out for an aborted takeoff, and when they recognized the need to abort the takeoff, it was too late to avoid a runway excursion.

## Factual narrative

The flight to Brunswick, Georgia, was originally scheduled to be flown in a Learjet 45 that was operated by Jet Access Aviation, a "sister" company of Honaker Aviation. Although the Learjet 45 was on the Part 135 certificate of Jet Access, the flight itself was scheduled as a Part 91 flight since the passengers were guests of the airplane's owner and the flight was not for financial remunerations. However, the Learjet's cockpit windshield needed repair, so the flight was rescheduled to be flown in the Beech 100, which was also partially owned by the owner of the Learjet 45. Although the Beech 100 is a single-piloted airplane, the owner required that a copilot be added to the flight. The airplane was a twin-engine Beech 100, serial number B-21, manufactured in 1969, powered by two 680-shaft horsepower P&W PT6A-28 engines. Its maximum gross takeoff weight was 10,600 lbs and had seating for 2 pilots and 8 passengers. The most recent continuous airworthiness maintenance inspection was performed on May 6, 2016, with a total airframe time of 12,583 hours. The pilot reported that the gross weight of the accident airplane was 11,223 lbs, which was 623 lbs over the maximum gross takeoff weight. The Beech King Air 100 Pilot's Operating Manual's performance charts indicated that the take-off distance at the maximum gross takeoff weight of 10,600 lbs with no flaps was about 2,100 ft. The performance chart for the distance to accelerate to decision speed (100 kts) and stop with no flaps at the maximum gross takeoff weight of 10,600 lbs was about 3,900 ft. On October 30, 2016, about 1235 eastern daylight time, a Beech 100, N411HA, sustained substantial damage during takeoff when it went off the departure end of runway 18 (5,500 ft by 100 ft, asphalt) at the Clark Regional Airport (JVY), Jeffersonville, Indiana. The pilot, copilot, and 8 passengers were not injured. The airplane was registered to RC AIR LLC and operated by Honaker Aviation under the provisions of the 14 Code of Federal Regulations as a Part 91 personal flight. Visual meteorological conditions prevailed at the time of the accident, and the flight was on an instrument flight rules flight plan. The flight was departing JVY and was en route to the McKinnon St. Simons Island Airport (SSI), Brunswick, Georgia. The pilot reported that he had received a trip sheet the day prior to the flight that indicated he would be flying a group of 9 male golfers along with their golf clubs on the flight. The pilot contacted the operator and questioned the accuracy of the trip sheet since the Beech 100 had only 8 passenger seats. The operator informed the pilot that the trip sheet was sent to him in error and that the flight he was actually scheduled for was to take 8 female passengers and their luggage to Brunswick, Georgia. Additionally, although the Beech 100 was a single-piloted airplane, a copilot would be flying with him on the flight. The pilot reported that he was concerned about taking 8 passengers withtheir luggage and how much fuel he could put on the airplane for the flight. He typically flew with 1 – 4 passengers, and this was the first time he flew with 8 passengers filling all the passenger seats. The pilot arrived at the airport the next morning and determined that the airplane had 900 lbs of fuel onboard. He instructed the lineman to fuel the airplane with 211 gallons of fuel (1,413.7 lbs) which brought the fuel total to 2,313.7 lbs (full fuel). That would ensure that he could fly to SSI without having to make a fuel stop en route. The pilot reported that he was aware that the total weight of the 8 passengers with their bags and the weight of the fuel caused the airplane to be overweight, but he did not complete a weight and balance form before the flight. Also, the bags were not weighed and the weights of the passengers were not determined. He informed the copilot that the flight would be heavy, but he did not tell him how much the it exceeded the maximum gross takeoff weight of the airplane. The pilot reported that the airplane's flight controls and engines were operating normally during the pre-takeoff check, and the elevator pitch trim was positioned in the "green" range. He stated that he did not give the copilot a departure briefing so the copilot was unaware of the airspeed callouts or what power settings were required. The pilot taxied onto runway 18 and applied the brakes and increased the throttles to takeoff power before releasing the brakes for the takeoff roll. The pilot stated that he did not confirm the power settings that he applied when he advanced the throttles. He stated that the airplane did not accelerate as quickly as he expected during takeoff roll. The airplane was about 1/2 way down the runway and the airspeed was 80 kts, so he continued the takeoff roll but the airplane was still not accelerating as expected. He stated that he heard the copilot say "redline" so he decreased the power. The airplane was in the last 1/3 of the runway and he pulled back on the control yoke to lift the airplane off the runway, but the stall warning sounded. He lowered the nose, but now the airplane was near the end of the runway. The pilot stated that he didn't get "on" the brakes or put the propellers into reverse pitch, and the airplane departed the runway. The pilot veered the airplane to the right to avoid an instrument landing system (ILS) antenna. The left wing hit the ILS antenna located 500 ft from the end of runway 18, and the left main gear and nose gear collapsed with both propellers contacting the ground. The airplane skidded back to the left before stopping about 680 ft from the end of the runway. Once the airplane stopped, the pilot opened the cabin door and assisted the passengers in evacuating the airplane. The copilot shut off the fuel to both engines and turned off the main battery bus. There was no post-crash fire. The pilot reported that the airplane did not have a mechanical malfunction or failure before theaccident occurred. At 1153, the surface weather observation at the Bowman Field Airport (LOU), Louisville, Kentucky, located about 9 nm southeast of JVY, was: wind 210 degrees at 8 kts; visibility 10 miles; sky clear; temperature 23 degrees C; dew point 14 degrees C; altimeter 30.07 inches of mercury. The 51-year-old pilot had an airline transport pilot certificate with single-engine land, multi-engine land, and airplane instrument ratings. He also held a flight instructor certificate with airplane single-engine and airplane instrument ratings. He held a first class medical certificate issued on August 16, 2016. He had a total of 13,142 total flight hours with 34 hours in the Beech 100. The pilot was hired by the operator, Honaker Aviation, on July 14, 2016. He stated that he went to Atlanta, Georgia, on July 15, 2016, for King Air 90/200 recurrent training. At Honaker Aviation, he flew the Beech F-90, Beech 100, and the Cessna Citation I. He had flown 117.2 hours since being hired. He flew 77.1 hours in the Beech 100, 33.9 hours in the Beech F-90, and 6.2 hours in the Citation I. The pilot stated that he had flown about 7,900 hours in a the single-pilot Metroliner for another operator. He stated that he had other flight experience in Beech King Air airplanes that included 570 hours in a Beech 99, 215 hours in a King Air 200, and 170 hours in a King Air 300. The 55-year-old copilot had a commercial pilot certificate with single-engine land, multi-engine land, and airplane instrument ratings. He held a second class medical certificate that was issued on January 8, 2016. He had a total of 1,605 flight hours with 3 hours in the Beech 100. He was hired by Honaker Aviation in March 2016 as a copilot on a Beechjet 400A, and had logged about 200 hours of flight time in the Beechjet 400A since being hired. He did not have any formal training in the Beech 100 and this was his second flight as a copilot on the Beech 100. The owner of Honaker Aviation reported that the copilot was acting as a "safety" copilot in case the pilot had an incapacitating event, at which time, the copilot would take control of the airplane and land. The copilot was not expected to know the airplane's systems, limitations, or performance characteristics of the airplane. The airplane's left wing sustained substantial damage to the spar. The left main landing gear and nose gear both collapsed and both engines and propellers were damaged during the accident.

## Aircraft

- Registration: [N411HA](https://openairdocs.org/deregistered/N411HA-2018-11-28), registration cancelled 2018-11-28, S/N B-21, built 1969 (OpenAirDocs)
- Reported make and model: BEECH 100
- Registry model: [Beech 100](https://openairdocs.org/model/beech-100) (registry code 1152916) (OpenAirDocs)
- Registry engine: [Pratt & Whitney Canada PT6A-60A](https://openairdocs.org/engine/pratt-whitney-canada-pt6a-60a) (registry code 52043, turbo-prop) (OpenAirDocs)
- Category: Airplane
- Serial number: B-21
- Year built: 1969
- Airframe hours: 12583
- Engines: P&W CANADA PT6A-28 1127 lbs thrust turbo prop; P&W CANADA PT6A-28 1127 lbs thrust turbo prop
- Damage: Substantial damage
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Continuous airworthiness, May 6, 2016
- Departed: JVY, Jeffersonville, IN
- Destination: SSI, Brunswick, GA
- Flight plan: IFR
- Airport: JVY, Clark Regional Airport, runway 18, 5,500 × 100 ft, asphalt
- Equipment: Stall warning system, Auto-pilot

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 51; injuries: none; airline transport, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review July 15, 2016; seat: left; restraint: 3-point; flight hours: 13,142 total, 34 in this make and model, 10,442 as pilot in command, 112 in the last 90 days, 26 in the last 30 days
- Co-pilot; age 55; injuries: none; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review March 28, 2016; seat: right; restraint: 3-point; flight hours: 1,605 total, 3 in this make and model, 1,305 as pilot in command, 73 in the last 90 days, 19 in the last 30 days

## Weather

- Conditions: Visual (VMC), Day
- Wind: 210° at 8 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 73 °F, dew point 57 °F
- Altimeter: 30.06 inHg
- Observed at: LOU, 9 nm away

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20161030022429A](https://openairdocs.org/incident/20161030022429A), Oct 30, 2016: Beech 100, Sellersburg, IN, Substantial damage. On October 30, 2016 about 1230 eastern standard time, a Beech 100 king air, tail number N411HA with two crew members and eight passengers onboard, departed…

## Docket (11 files)

The files NTSB released with the investigation on December 1, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94314. 8.6 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446871&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF
- Co-Pilot's Statement (item 2, .PDF, 583 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446872&FileExtension=.PDF&FileName=Co-Pilot%27s%20Statement-Master.PDF
- Passenger Statements (item 3, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446873&FileExtension=.PDF&FileName=Passenger%20Statements-Master.PDF
- NTSB Record of Conversations (item 4, .PDF, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446874&FileExtension=.PDF&FileName=NTSB%20Record%20of%20Conversations-Master.PDF
- Aerial Views of Airport and Accident Site (item 5, .PDF, 381 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446875&FileExtension=.PDF&FileName=Aerial%20Views%20of%20Airport%20and%20Accident%20Site-Master.PDF
- Honaker Trip Sheet (item 6, .PDF, 345 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446876&FileExtension=.PDF&FileName=Honaker%20Trip%20Sheet-Master.PDF
- W&B for N411HA (item 7, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446877&FileExtension=.PDF&FileName=W%26B%20for%20N411HA-Master.PDF
- Weight and Balance Information (item 8, .PDF, 638 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446878&FileExtension=.PDF&FileName=Weight%20and%20Balance%20Information-Master.PDF
- Pilot Training Records (item 9, .PDF, 427 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446879&FileExtension=.PDF&FileName=Pilot%20Training%20Records-Master.PDF
- Co-Pilot's Training Records (item 10, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446880&FileExtension=.PDF&FileName=Co-Pilot%27s%20Training%20Records-Master.PDF
- Photo Log (item 11, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446881&FileExtension=.PDF&FileName=Photo%20Log-Master.PDF

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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