GAA19CA011

NTSB accident investigation · Beech 55 · San Antonio, TX · October 5, 2018

Accident · Minor injuriesData collectionFinal report
Date
October 5, 2018, 11:30 local (16:30 UTC)
Place
San Antonio, TX
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N6674YBeech 55
Defining event
Takeoff: Abrupt maneuver
Weather
Visual (VMC) · Day
Status
Completed · report April 8, 2019
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA
FAA report
20181005016709A
Case key
98435

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 takeoff trim setting and failure to properly secure his seatbelt, which resulted in a loss of airplane control. Contributing to the accident was the pilot's failure to follow the Before Takeoff checklist.

Findings · 7

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: elevator tab control systemAircraft › Aircraft systems · Incorrect use/operationBeech E-55: 1 caseAll aircraft: 37 casesProbable cause
Equipment/furnishings: flight compartment equipmentAircraft › Aircraft systems · Incorrect use/operationBeech E-55: 1 caseAll aircraft: 37 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotBeech E-55: 4 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: pitch controlAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleBeech E-55: 1 caseAll aircraft: 526 casesProbable cause
Use of equip/info: use of checklistPersonnel issues › Task performance · PilotBeech E-55: 1 caseAll aircraft: 336 casesProbable cause
Object/animal/substance: runway/taxi/approach lightEnvironmental issues › Physical environment · Contributed to outcomeBeech E-55: 1 caseAll aircraft: 106 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, the day before the accident flight, he had flown the airplane and wanted to become more comfortable with new instruments that had been installed. So, after the flight, while in a hangar, he and a friend turned the airplane's electrical power on to familiarize the pilot with the autopilot system and specifically with how it would follow heading bug settings. During the familiarization, they "ran the [pitch] trim all the way up." The pilot added that, before takeoff for the accident flight, he did not check the pitch trim setting because he believed it would be the same as his previous flight, instead of the pitch trim setting after his autopilot ground familiarization. He added that, during takeoff, the nose pitched up severely. He lowered the nose, and the airplane entered a negative G condition. He realized that he "did not latch the seat belt very good" and saw that his seatbelt had disconnected and that he was no longer in his seat and could not regain airplane control. The airplane struck the runway, porpoised, and the nose landing gear collapsed. The airplane skidded and struck a taxiway light. Postaccident examination of the airplane revealed that the vertical trim tab was in the full-down position, indicating that full nose-up trim was applied. The airplane sustained substantial damage to both engines and the fuselage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The Pilot's Operating Handbook checklist titled, "Before Takeoff," stated: Seat Belts and Shoulder Harnesses – CHECK… 15. Trim – AS REQUIRED FOR TAKE-OFF

Factual narrative

The pilot reported that, the day before the accident flight, he had flown the airplane, and wanted to become more comfortable with the new instruments which had been installed. So, after the flight, while in a hangar, he and a friend turned the airplane's electrical power on to familiarize the pilot with the autopilot system, and specifically how it would follow heading bug settings. During the familiarization, they "ran the [pitch] trim all the way up". The pilot added that, during the accident flight, before takeoff, he did not check the pitch trim setting because he believed it would be the same as his previous flight, instead of the pitch trim setting after his autopilot ground familiarization. He added that, during takeoff, the nose pitched up severely. He lowered the nose, entered a negative G condition, discovered that he "did not latch the seat belt very good" and observed his seat belt had disconnected, and he was no longer in his seat and could not regain airplane control. The airplane struck the runway, porpoised, and on the third cycle, the nose landing gear collapsed. The airplane skidded and struck a taxiway light. Postaccident examination of the airplane revealed that the vertical trim tab was in the "full down position," indicating that full nose-up trim was applied. The airplane sustained substantial damage to the both engines and fuselage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The pilot operating handbook checklist titled "Before Takeoff" stated: 1. Seat Belts and Shoulder Harnesses – CHECK It continued: 15. Trim – AS REQUIRED FOR TAKE-OFF

Aircraft

Registration
N6674Y
Reported as
Beech 55 (E55)
Category
Airplane
Serial number
TE-1168
Built
1979
Airframe hours
5,414.5
Engines
Continental IO-520-CB, 285 horsepower, reciprocatingContinental IO-520-CB8B, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 20, 2017
Departed
SAT · San Antonio, TX
Destination
SAT · San Antonio, TX
Airport
SAT · San Antonio Intl, runway 13R, 8,502 × 150 ft, concrete
Equipment
Electronic multifunction display, Electronic flight bag or handheld device, Electronic primary flight display, Onboard weather, ADS-B, Auto-pilot

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
79
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
September 20, 2015
Seat
Left
Restraint
Lap only
Flight hours
3,907 total · 1,322 in this make and model · 3,897 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 9 knots
Visibility
10 statute miles
Temperature
84 °F, dew point 70 °F
Altimeter
30.00 inHg
Observed at
KSAT

Docket · 4

The files NTSB released with the investigation on December 17, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.5 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.