# NTSB GAA19CA011: Beech 55, N6674Y, San Antonio, TX, October 5, 2018 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: October 5, 2018, 11:30 local (16:30 UTC) - Place: San Antonio, TX - Coordinates: 29.538888, -98.480278 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.5389&lon=-98.4803&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Abrupt maneuver](https://openairdocs.org/ntsb-events/270) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report April 8, 2019 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 98435 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA011 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98435/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98435 - Page: https://openairdocs.org/ntsb/GAA19CA011 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Flight control system: elevator tab control system](https://openairdocs.org/ntsb-findings/01022731): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Beech E-55, 1 case](https://openairdocs.org/ntsb-findings/01022731/cases.md?model=1152732), [All aircraft, 37 cases](https://openairdocs.org/ntsb-findings/01022731/cases.md) - [Equipment/furnishings: flight compartment equipment](https://openairdocs.org/ntsb-findings/01022510): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Beech E-55, 1 case](https://openairdocs.org/ntsb-findings/01022510/cases.md?model=1152732), [All aircraft, 37 cases](https://openairdocs.org/ntsb-findings/01022510/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 E-55, 4 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1152732), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Attention/monitoring: task monitoring/vigilance](https://openairdocs.org/ntsb-findings/02021520): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Beech E-55, 1 case](https://openairdocs.org/ntsb-findings/02021520/cases.md?model=1152732), [All aircraft, 330 cases](https://openairdocs.org/ntsb-findings/02021520/cases.md) - [Performance/control parameters: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Beech E-55, 1 case](https://openairdocs.org/ntsb-findings/01062022/cases.md?model=1152732), [All aircraft, 526 cases](https://openairdocs.org/ntsb-findings/01062022/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 E-55, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=1152732), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) - [Object/animal/substance: runway/taxi/approach light](https://openairdocs.org/ntsb-findings/03022012): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Beech E-55, 1 case](https://openairdocs.org/ntsb-findings/03022012/cases.md?model=1152732), [All aircraft, 106 cases](https://openairdocs.org/ntsb-findings/03022012/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: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Beech E-55, 2 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=1152732), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Takeoff: Abrupt maneuver](https://openairdocs.org/ntsb-events/270) (defining event); cases with it: [Beech E-55, 1 case](https://openairdocs.org/ntsb-events/270/sequence.md?model=1152732), [All aircraft, 346 cases](https://openairdocs.org/ntsb-events/270/sequence.md) - [Takeoff: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [Beech E-55, 1 case](https://openairdocs.org/ntsb-events/090/sequence.md?model=1152732), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) - [Takeoff: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [Beech E-55, 3 cases](https://openairdocs.org/ntsb-events/094/sequence.md?model=1152732), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) - [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech E-55, 6 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1152732), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N6674Y-2019-06-18), registration cancelled 2019-06-18, S/N TE-1168, built 1979 (OpenAirDocs) - Reported make and model: Beech 55 (E55) - Registry model: [Beech E-55](https://openairdocs.org/model/beech-e-55) (registry code 1152732) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TE-1168 - Year built: 1979 - Airframe hours: 5414.5 - Engines: Continental IO-520-CB 285 horsepower reciprocating; Continental 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 79; injuries: minor; 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 ## 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 20181005016709A](https://openairdocs.org/incident/20181005016709A), Oct 5, 2018: Beech E-55, San Antonio, TX, Substantial damage. During the rotation sequence of the takeoff at sat the pilot lost vertical control of the aircraft due to the trim being in the full nose down position.… ## Docket (4 files) The files NTSB released with the investigation on December 17, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98435. 1.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469574&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation - Pilot (item 2, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469575&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot-Master.PDF - POH Checklist Excerpt (item 3, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469576&FileExtension=.PDF&FileName=POH%20Checklist%20Excerpt-Master.PDF - Accident Photo (item 4, .PDF, 1 photo, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469577&FileExtension=.PDF&FileName=Accident%20Photo-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.