# NTSB CEN23LA363: Beech C-99, N261SW, Lansing, MI, August 15, 2023 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 4 · Limited · Final report - Date: August 15, 2023, 08:05 local (12:05 UTC) - Place: Lansing, MI - Coordinates: 42.778237, -84.586755 - Nearby events: https://openairdocs.org/map.md?lat=42.7782&lon=-84.5868&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Central Region - Parties: FAA-FSDO - NTSB case key (mKey): 192876 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23LA363 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192876/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=192876 - Page: https://openairdocs.org/ntsb/CEN23LA363 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Flight control system: rudder tab control system](https://openairdocs.org/ntsb-findings/01022721): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Beech C-99, 1 case](https://openairdocs.org/ntsb-findings/01022721/cases.md?model=1154006), [All aircraft, 6 cases](https://openairdocs.org/ntsb-findings/01022721/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech C-99, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=1154006), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech C-99, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=1154006), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) - [Policy/procedure: adequacy of policy/proc](https://openairdocs.org/ntsb-findings/04021015): Organizational issues › Management · Operator; cases with it: [Beech C-99, 2 cases](https://openairdocs.org/ntsb-findings/04021015/cases.md?model=1154006), [All aircraft, 106 cases](https://openairdocs.org/ntsb-findings/04021015/cases.md) - [Maintenance/inspections: return to service](https://openairdocs.org/ntsb-findings/01010530): Aircraft › Aircraft handling/service · Related maintenance info; cases with it: [Beech C-99, 1 case](https://openairdocs.org/ntsb-findings/01010530/cases.md?model=1154006), [All aircraft, 14 cases](https://openairdocs.org/ntsb-findings/01010530/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech C-99, 3 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1154006), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Beech C-99, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=1154006), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Beech C-99, 1 case](https://openairdocs.org/ntsb-events/030/sequence.md?model=1154006), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Beech C-99, 3 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1154006), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Initial climb: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech C-99, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1154006), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N261SW-2023-12-07), registration cancelled 2023-12-07, S/N U-202, built 1983 (OpenAirDocs) - Reported make and model: BEECH C-99 - Registry model: [Beech C-99](https://openairdocs.org/model/beech-c-99) (registry code 1154006) (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: U-202 - Year built: 1983 - Airframe hours: 27642.9 - Engines: Pratt & Whitney PT6A-36 750 horsepower turbo prop; Pratt & 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 27; injuries: minor; 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= ## 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 20230815009959A](https://openairdocs.org/incident/20230815009959A), Aug 15, 2023: Beech C-99, Lansing, MI, Substantial damage. On August 15th, 2023 at approximately 08:10 local time a Beech C-99, [privacy data omitted], operated by a 135 air carrier and piloted by a commercial licensed… ## Docket (4 files) The files NTSB released with the investigation on November 9, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=192876. 37.5 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 5.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16175923&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Photo array (item 2, PDF, 1 page, 662 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16175653&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Pilot's statement (item 3, PDF, 2 pages, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16175768&FileExtension=pdf&FileName=Pilot%20Statement-Rel.pdf - BE-99C normal procedures checklist (item 4, PDF, 2 pages, 31.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16176589&FileExtension=pdf&FileName=Ameriflight%20BE-99C%20Normal%20Procedures%20Checklist_Redacted-Rel.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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.