CEN23LA363

NTSB accident investigation · Beech C-99 · Lansing, MI · August 15, 2023

Accident · Minor injuriesClass 4 · LimitedFinal report
Date
August 15, 2023, 08:05 local (12:05 UTC)
Place
Lansing, MI
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N261SWBeech C-99
Defining event
Initial climb: Loss of control in flight
Weather
Instrument (IMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 4 - Basic report with no Prelim publish
NTSB office
Central Region
Parties
FAA-FSDO
FAA report
20230815009959A
Case key
192876

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot’s failure to properly set the rudder trim position which resulted in a loss of directional control during takeoff. Contributing was the pilot’s inadequate checklist procedures prior to takeoff.

Findings · 6

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Flight control system: rudder tab control systemAircraft › Aircraft systems · Incorrect use/operationBeech C-99: 1 caseAll aircraft: 6 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotBeech C-99: 1 caseAll aircraft: 551 casesProbable cause
Use of equip/info: use of checklistPersonnel issues › Task performance · PilotBeech C-99: 1 caseAll aircraft: 336 casesProbable cause
Maintenance/inspections: return to serviceAircraft › Aircraft handling/service · Related maintenance infoBeech C-99: 1 caseAll aircraft: 14 cases
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotBeech C-99: 3 casesAll aircraft: 9,295 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported that after a normal start and taxi, the airplane was cleared for takeoff. During the takeoff roll, the airplane drifted right and the pilot corrected with the left rudder. When the airplane reached 100 knots, he rotated the airplane, and about 30 feet in altitude, the airplane experienced a roll to the right. The pilot tried to correct the roll with left rudder but was unable to provide sufficient left rudder. At this point, the airplane had drifted to the right of the runway and over the adjacent parallel taxiway. He was able to regain partial control by reducing engine power and banking the airplane to the left. The pilot attempted to land on the taxiway but was unable to judge his height above ground due to the low visibility, and subsequently impacted terrain to the right of the taxiway. Both wings and the fuselage sustained substantial damage. Prior to exiting the airplane, the pilot noted that the rudder trim was set to the full nose-right position. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. Prior to the accident, maintenance was completed that consisted of an “Event II & Routine” inspection. The inspection procedure required the rudder trim system to be lubricated, a trim tab free play inspection, and an operational check prior to returning the airplane to service. Review of the maintenance procedures revealed there was no guidance on returning the rudder trim control system back to a neutral position at completion of the inspection.

Aircraft

Registration
N261SW
Reported as
Beech C-99
Category
Airplane
Serial number
U-202
Built
1983
Airframe hours
27,642.9
Engines
Pratt & Whitney PT6A-36, 750 horsepower, turbo propPratt & Whitney PT6A-36, 750 horsepower, turbo prop
Damage
Substantial damage
Flight
Part 135
Operator
Ameriflight, LLC, doing business as Ameriflight
Registered owner
Uas Transervices Inc
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · August 14, 2023
Departed
LAN · Lansing, MI
Destination
KPLN · Pellston, MI
Flight plan
IFR
Airport
LAN · Captial Regional International, runway 10R, 8,506 × 150 ft, asphalt
Equipment
Electronic flight bag or handheld device, Auto-pilot, ADS-B, Stall warning system, Electronic multifunction display

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
27
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
August 4, 2023
Seat
Right
Restraint
4-point
Flight hours
1,218 total · 26 in this make and model · 397 as pilot in command · 66 in the last 90 days · 26 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
40° at 18 knots, gusting 27
Visibility
0.75 statute miles
Lowest ceiling
3,900 ft broken
Temperature
63 °F, dew point 59 °F
Altimeter
29.80 inHg
Observed at
KLAN, 1 nm away
METAR
KLAN 151226Z 04018G27KT 1 3/4SM R28L/6000VP6000FT +RA BR SCT011 BKN039 OVC080 17/15 A2980 RMK AO2 PK WND 05027/1225 P0008 T01670150=

Docket · 4

The files NTSB released with the investigation on November 9, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 37.5 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.