# NTSB GAA18CA109: Beech B60, Scottsdale, AZ, January 16, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: January 16, 2018, 16:00 local (23:00 UTC) - Place: Scottsdale, AZ - Coordinates: 33.621112, -111.91333 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.6211&lon=-111.9133&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report June 14, 2018 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 96629 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA18CA109 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96629/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96629 - Page: https://openairdocs.org/ntsb/GAA18CA109 ## Probable cause The pilot’s improper brake application during landing, which resulted in a tire blowout and a loss of directional control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Landing gear system: brake](https://openairdocs.org/ntsb-findings/01023242): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md) - [Object/animal/substance: sign/marker](https://openairdocs.org/ntsb-findings/03022015): Environmental issues › Physical environment · Contributed to outcome; cases with it: [All aircraft, 214 cases](https://openairdocs.org/ntsb-findings/03022015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Landing: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Landing: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Landing: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) ## 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 (not matched to a registry record) - Reported make and model: BEECH B60 - Category: Airplane - Serial number: P-595 - Year built: 1982 - Airframe hours: 4027.3 - Engines: Lycoming TIO-541-E1C4 380 horsepower reciprocating; Lycoming 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 As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: none; 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 - Pilot; age 59; injuries: none; 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 files) The files NTSB released with the investigation on April 18, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96629. 5.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462025&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Logbook Entries (item 2, .PDF, 710 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462026&FileExtension=.PDF&FileName=Logbook%20Entries-Master.PDF - Record of Conversation - Airport Operations Manager (item 3, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462027&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Airport%20Operations%20Manager-Master.PDF - Record of Conversation - Mechanic (item 4, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462028&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Mechanic-Master.PDF - Accident Photos (Courtesy of FAA) (item 5, .PDF, 2 photos, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462029&FileExtension=.PDF&FileName=Accident%20Photos%20(Courtesy%20of%20FAA)-Master.PDF - Brake Exam Notes (item 6, .PDF, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462030&FileExtension=.PDF&FileName=Brake%20Exam%20Notes-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. --- 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.