ERA24LA012

NTSB accident investigation · Beech 300 · Atlanta, GA · October 18, 2023

Accident · No injuriesClass 3 · LimitedFinal report
Date
October 18, 2023, 15:11 local (19:11 UTC)
Place
Atlanta, GA · EMAS end of Runway 21L
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N93GABeech 300
Defining event
Landing-landing roll: Runway excursion
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Textron Aviation, Inc.
FAA report
20231018020679A
Case key
193271

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

On this page

Probable cause

The pilot’s failure to maintain a proper approach speed, which resulted in a runway overrun. Contributing to the runway overrun were the pilot’s application of full reverse at an airspeed higher than that allowed by the system, which added power and forward thrust, and the application of braking that flat-spotted the main landing gear tires.

Findings · 4

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.

Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Incorrect use/operationBeech 300: 1 caseAll aircraft: 1,681 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotBeech 300: 1 caseAll aircraft: 1,391 casesProbable cause
Engine (turbine/turboprop)Aircraft › Aircraft power plant · Incorrect use/operationBeech 300: 1 caseAll aircraft: 67 casesProbable cause
Landing gear system: tire casingAircraft › Aircraft systems · Damaged/degradedBeech 300: 1 caseAll aircraft: 36 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 performed a visual approach to the runway in calm wind conditions with the flaps extended halfway (approach flaps). Flight track information indicated that the airplane was fast crossing the runway displaced threshold, and touched down with about 4,000 ft of runway remaining at a speed about 135 knots (kts), which was 19 kts above the highest published approach speed for the airplane’s gross weight at the time of landing. The pilot reported that, after touchdown, he moved the power levers into the ground fine position to help slow the airplane, but he did not feel the “normal deceleration.” He applied the brakes and then “stood on the brakes,” adding that he did not feel the tires sliding, then applied maximum reverse thrust in an attempt to bring the airplane to a stop on the runway. The airplane rolled past the departure end of the runway, onto a displaced threshold, and then into the engineered material arresting system past the departure end of the runway. During the runway excursion, the nose landing gear wheel assembly separated and the right engine was displaced from its normal position. Postaccident examination revealed that one tire on each main landing gear exhibited flat-spotting through the tread, consistent with a sliding tire. Although the pilot commanded the propeller blade angle to move less than the flight idle low pitch stop setting during the landing roll, the propeller blades could not move to this position until the airplane slowed to about 100 kts or less, which did not occur until the airplane was more than 3,400 ft down the 5,000-ft-long runway. At speeds above 100 kts, the propeller was governed by the constant speed unit, which will not allow the pilot to command ground fine or reverse thrust settings. Thus, there were no systems failures or malfunctions that prevented movement of the propeller blades to ground fine or reverse. The application of full reverse thrust when the airplane was likely greater than 100 kts indicated airspeed likely further increased the required stopping distance by adding engine power and thrust in the forward direction. The added forward thrust, combined with the flat-spotting of several tires during the landing roll, likely cumulatively increased the required landing roll distance, resulting in insufficient runway remaining to avoid a runway overrun.

Factual narrative

The airplane was equipped with avionics that could record and retain flight and engine data; however, a secure digital (SD) card was not in the appropriate slot of any of the avionics. Therefore, flight and engine data were not available for the accident flight. The airplane was also equipped with five-blade, constant speed, full feathering and reversing propellers. The Flight Manual Supplement associated with the propeller installation specified that there was no change to the constant speed propeller governor or constant speed unit (CSU), and the performance was equal to or better than the baseline airplane. According to the propeller manufacturer, with the propeller levers full forward, the propeller would still be controlled by the governor to about 100 kts indicated airspeed (KIAS). According to the airplane Pilot’s Operating Handbook and Federal Aviation Administration Approved Airplane Flight Manual (POH/AFM), as part of the normal landing checklist, the propeller levers were to be placed full forward. After touchdown, the power levers were to be lifted and moved aft into the ground fine position, which would provide optimum deceleration by taking advantage of the maximum available propeller drag. The systems description of the POH/AFM indicated that at touchdown, with activation of the low pitch stop solenoid by the right squat switch, propeller blade angle can only move from the flight idle low pitch stop setting to the ground idle low pitch stop setting when the propeller is no longer controlled by the governor or CSU and when there is movement of the power lever from Flight Idle to Ground Fine. The pilot indicated that the airplane’s landing weight was 10,836 lbs. The POH/AFM published Vref speeds at 11,000 pounds for a 3° approach with flaps down and up were 93 kts and 116 kts, respectively. There was no landing distance chart for the approach flaps setting. A review of over 90 days of an electronic flight log, which included the accident flight, revealed no comments regarding propeller blade angle below flight idle. Excluding the accident flight, the accident pilot was listed as flight crew on 28 of the 29 flights. He later stated that he had not experienced any landing sequence anomaly associated with the ground fine propeller setting during any of the previous landings. Runway 21L was about 6,000 ft long and equipped with a displaced threshold, making about 5,000 ft of landing distance available. EMAS was installed past the departure end of the runway. On October 18, 2023, about 1511 eastern daylight time, a Beech 300, N93GA, was substantially damaged when it was involved in an accident near Atlanta, Georgia. The airline transport pilot and one passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. The pilot reported that, during the approach for landing, the airplane’s speed was 162 knots (kts) at 500 ft above ground level, which was above the speed for full flapextension. The pilot then chose to perform a normal half-flaps landing. He later reported that he was following a jet on final approach and was flying a slightly high approach path with partial flaps, anticipating a potential go-around. He stated that the airplane touched down “slightly long,” but he felt he had plenty of runway on which to stop. Review of flight track information revealed that the airplane crossed the runway displaced threshold at a calibrated airspeed of 150 knots (kts), which was 30 kts faster than the conservative no-flaps landing approach speed reported by the pilot (120 kts) and 34 kts faster than the published no-flap approach speed for the airplane’s weight. The airplane touched down about 1,000 ft past the displaced threshold at 135 kts calibrated airspeed. The pilot reported that, after touchdown, he moved each power lever to the ground fine position, but he did not hear the normal propeller pitch sound change nor detect deceleration. He applied the brakes, then “stood on the toe brakes” and applied maximum reverse. He later stated that it was not normal to select reverse when landing in the accident airplane. Review of flight track and aircraft performance data indicated that the airplane did not slow to 100 kts calibrated airspeed until slightly more than 3,400 ft down the runway, with only about 1,600 ft of runway remaining. The pilot was unable to stop the airplane before rolling past the departure end of the runway onto the displaced threshold and then into an engineered material arresting system (EMAS) at a groundspeed about 40 kts. The airplane came to rest in the EMAS in a nose-low attitude. Aviation surface observation reports taken about 18 minutes before the accident and 42 minutes after the accident reported in part, calm wind, and a variable wind at 5 knots, respectively. A one-minute wind report taken at the time of the accident reported wind from 330° magnetic at 1 knot. Postaccident examination of the airplane, which was not equipped with a brake antiskid system, revealed that all main landing gear tires were deflated, and the outer tire on each main landing gear exhibited flat-spotting through the tread. The nose landing gear wheel and tire assembly with fork and axle assembly and attached lower knee was separated from the nose landing gear and found in proximity to the main wreckage. The right engine assembly was displaced down with structural damage behind/at the firewall noted.

Aircraft

Registration
N93GA
Reported as
Beech 300 (UNDESIGNATED SERIES)
Category
Airplane
Serial number
FA-93
Built
1986
Airframe hours
10,459
Engines
Pratt & Whitney Canada PT6A-60, 1,050 lbs thrust, turbo propPratt & Whitney Canada PT6A-60, 1,050 lbs thrust, turbo prop
Damage
Substantial damage
Flight
Business · Part 91
Operator
Csw Aviation LLC
Registered owner
Csw Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · December 23, 2022 · 139 hours before
Departed
SAV · Savannah, GA
Destination
Same as departure
Flight plan
IFR
Airport
PDK · DeKalb-Peachtree Airport, runway 21L, 5,001 × 100 ft, concrete
Equipment
Electronic primary flight display, Electronic multifunction display, Auto-pilot, ADS-B, Stall warning system, Onboard weather

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
57
Injuries
None
Certificates
Flight instructor, Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
September 23, 2022
Seat
Left
Restraint
4-point
Flight hours
6,319 total · 2,610 in this make and model · 4,932 as pilot in command · 62 in the last 90 days · 19 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 46 °F
Altimeter
30.13 inHg
Observed at
KPDK, 1 nm away
METAR
KPDK 181853Z 00000KT 10SM CLR 19/08 A3013 RMK AO2 SLP202 T01940078

Docket · 21

The files NTSB released with the investigation on December 5, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 25.6 MB in all.

Pilot/operator aircraft accident report, NTSB form 6120.1Item 1 · PDF · 11 pages · 4.6 MBPilot initial statementItem 2 · PDF · 1 page · 933 KBPilot additional statement and informationItem 3 · PDF · 3 pages · 193 KBAdditional questions to pilot and attorney with responsesItem 4 · PDF · 3 pages · 77 KBPassenger statementItem 5 · PDF · 1 page · 2.7 MBExcerpts from pilot's operating handbook and federal aviation administration approved airplane flight manualItem 6 · PDF · 7 pages · 929 KBExcerpts from maintenance manualItem 7 · PDF · 3 pages · 820 KBElectronic flight logItem 8 · PDF · 1 page · 138 KBFAA 337 form for propeller installationItem 9 · PDF · 2 pages · 541 KBFlight manual supplement due to propeller installationItem 10 · PDF · 9 pages · 475 KBMemorandum for record - primary flight display and multi-function display secure digital (SD) card placement and storage.Item 11 · PDF · 2 pages · 1 photo · 326 KBNTSB memorandum for record - airspeed for propeller governingItem 12 · PDF · 2 pages · 71 KBMemorandum for record - observed wind informationItem 13 · PDF · 2 pages · 85 KBFederal aviation administration chronological summary of flight communicationsItem 14 · PDF · 6 pages · 1.7 MBNTSB prepared partial transcription of communications - local control 1.Item 15 · PDF · 1 page · 47 KBInvestigative photographsItem 16 · PDF · 10 pages · 9 photos · 3.9 MBAircraft performance studyItem 17 · PDF · 11 pages · 1 photo · 2.3 MBOpsvue data N93GAItem 18 · CSV · 100 KBADS-B data N93GAItem 19 · CSV · 5.0 MBStatement of party representatives to NTSB investigationItem 20 · PDF · 9 pages · 190 KBRelease of aircraft wreckage, NTSB form 6120.15Item 21 · PDF · 1 page · 312 KB

FAA reports on this event · 1

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