GAA18CA109

NTSB accident investigation · Beech B60 · Scottsdale, AZ · January 16, 2018

Accident · No injuriesData collectionFinal report
Date
January 16, 2018, 16:00 local (23:00 UTC)
Place
Scottsdale, AZ
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
CFESGBeech B60
Defining event
Landing: Loss of control on ground
Weather
Visual (VMC) · Day
Status
Completed · report June 14, 2018
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA
Case key
96629

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 improper brake application during landing, which resulted in a tire blowout and a loss of directional control.

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: directional controlAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleAll aircraft: 3,958 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotAll aircraft: 9,295 casesProbable cause
Landing gear system: brakeAircraft › Aircraft systems · Incorrect use/operationAll aircraft: 297 casesProbable cause
Object/animal/substance: sign/markerEnvironmental issues › Physical environment · Contributed to outcomeAll aircraft: 214 cases

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, during the approach, he flew the airplane about 10 knots faster than normal due to other traffic's wake turbulence. He added that, while decelerating during the landing roll, the airplane veered to the left. He applied right rudder but to no avail. The airplane veered off the runway to the left, struck a taxiway sign, and the nose landing gear collapsed. The airplane sustained substantial damage to the pressure vessel. During postaccident examination, the pilot observed that the left tire had blown out. The tire exhibited a flat, bald spot about the width of the tire. The tire fabric threads were visible around a hole in the tire, consistent with a skid. In a followup conversation with the National Transportation Safety Board (NTSB) investigator- in-charge (IIC), the pilot reported that, during the approach, he verified brake hydraulic pressure. He added that he checked that his heels were on the floor and that he was the sole manipulator of the controls during landing. The airport Operations Manager reported that, during the recovery process, there were no observed fluids around the main landing gear. He added that the airport surveillance video captured the landing sequence, which showed that there was "quite a bit of smoke" from the left tire during touchdown. The airplane's logbooks indicated that the most recent maintenance work was done a month before the accident. The mechanic who worked on the airplane reported that the pilot requested work on the oleo struts but not to the brake system. He added that, during the oleo strut maintenance, the brakes were unbolted and set aside until reassembly. After the oleo strut work was completed, the mechanic ran up the airplane, taxied around, and tested the brake with no observed abnormalities. An NTSB IIC and Federal Aviation Administration inspector examined the wreckage and the NTSB IIC reported that the left brake rotor was normal in color and had minimal wear; the right main landing gear was unremarkable. He added that the brake pedals were actuated, and pressure was heard at both main landing gear brake assemblies. The brake pedal foot pressure was also unremarkable.

Factual narrative

The pilot reported that, during approach, he flew the airplane about 10 knots faster than normal due to other traffic's wake turbulence. He added that, while decelerating during the landing roll, the airplane veered to the left. He applied right rudder, but to no avail. The airplane veered off the runway to the left, struck a taxiway sign, and the nose landing gear collapsed. The airplane sustained substantial damage to the pressure vessel. During a postaccident examination, the pilot observed that the left tire had blown out. The tire exhibited a flat, bald spot about the width of the tire. The tire fabric threads were visible around a hole in the tire, consistent with a skid. In a follow up conversation with the National Transportation Safety Board (NTSB) Investigator- In-Charge (IIC), the pilot reported that, during approach, he verified brake hydraulic pressure. He added that he checked that his heels were on the floor and that he was the sole manipulator of the controls during landing. The airport Operations Manager reported that, during the recovery process there were no observed fluids around the main landing gear. He added that the airport surveillance video captured the landing sequence. He observed, from the video, that there was "quite a bit of smoke" from the left tire during touchdown. The airplane's logbooks indicated that the most recent maintenance work was done a month prior to the accident. The mechanic who worked on the airplane reported that the pilot requested work on the oleo struts, but not to the brake system. He added that, during the oleo strut maintenance, the brakes were unbolted and set aside until reassembly. After the oleo strut work was completed, the mechanic ran up the airplane, taxied around, and tested the brake with no observed abnormalities. An NTSB investigator and Federal Aviation Administration inspector examined the wreckage and the NTSB investigator reported that the left brake rotor was normal in color and had minimal wear; the right main landing gear was unremarkable. He added that the brake pedals were actuated, and pressure was heard at both main landing gear brake assemblies. The brake pedal foot pressure was also unremarkable.

Aircraft

Registration
CFESG
Reported as
Beech B60
Category
Airplane
Serial number
P-595
Built
1982
Airframe hours
4,027.3
Engines
Lycoming TIO-541-E1C4, 380 horsepower, reciprocatingLycoming TIO-541-E1C4, 380 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
2190089 Ontario Inc.
Registered owner
2190089 Ontario Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 11, 2017
Departed
ABQ · Albuquerque, NM
Destination
SDL · Scottsdale, AZ
Flight plan
IFR
Airport
SDL · Scottsdale, runway 21, 8,249 × 100 ft, asphalt
Equipment
Onboard weather, Satellite tracking device, Stall warning system, ADS-B, Auto-pilot, Electronic multifunction display, Electronic primary flight display

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
65
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
April 14, 2017
Seat
Left
Restraint
3-point
Flight hours
901 total · 51 in this make and model · 606 as pilot in command · 19 in the last 90 days · 13 in the last 30 days · 7 in the last 24 hours
Role
Pilot
Age
59
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
March 17, 2017
Seat
Right
Restraint
3-point
Flight hours
17,000 total · 55 in this make and model · 16,500 as pilot in command · 30 in the last 90 days · 13 in the last 30 days · 7 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
110° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 27 °F
Altimeter
30.10 inHg
Observed at
KSDL

Docket · 6

The files NTSB released with the investigation on April 18, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.2 MB in all.