# NTSB LAX00GA158: Grumman US-2C, N7046U, Reno, NV, April 17, 2000 - Type: NTSB accident investigation - Classification: Accident · Fatal · Final report - Date: April 17, 2000, 10:35 local (17:35 UTC) - Place: Reno, NV - Coordinates: 39.667221, -119.876113 - Nearby events: https://openairdocs.org/map.md?lat=39.6672&lon=-119.8761&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report June 2, 2004 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 51201 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX00GA158 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/51201/pdf - Page: https://openairdocs.org/ntsb/LAX00GA158 ## Probable cause the flying pilot's failure to maintain directional control following a loss of engine power. Also causal was the failure of the flight crew to follow the published checklist and use the rudder assist system, and the decision not to abort the takeoff. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, takeoff - initial climb - 1 engine - reason for occurrence undetermined (cause) - Loss of control - in flight, takeoff - initial climb - aborted takeoff - not performed, pilot in command (cause) - checklist - not complied with, pilot in command (cause) - equipment,other - not used, pilot in command (cause) - airspeed(vyse) - not obtained/maintained, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis During the takeoff climb, the airplane turned sharply right, went into a steep bank and collided with terrain. The airplane began a right turn immediately after departure and appeared to be going slow. A witness was able to distinguish the individual propeller blades on the right engine, while the left engine propeller blades were indistinguishable. The airplane stopped turning and flew for an estimated 1/4-mile at an altitude of 100 feet. The airplane then continued the right turn at a steep bank angle before disappearing from sight. Then the witness observed a plume of smoke. White and gray matter, along with two ferrous slivers, contaminated the chip detector on the right engine. The airplane had a rudder assist system installed. The rudder assist provided additional directional control in the event of a loss of power on either engine. The NATOPS manual specified that the rudder assist switch should be in the ON position for takeoff, landing, and in the event of single-engine operation. The rudder boost switch was in the off position, and the rudder boost actuator in the empennage was in the retracted (off) position. The owner had experienced a problem with the flight controls the previous year and did not fly with the rudder assist ON. The accident flight had the lowest acceleration rate, and attained the lowest maximum speed, compared to GPS data from the seven previous flights. It was traveling nearly 20 knots slower, about 100 knots, than the bulk of the other flights when it attempted to lift off. The airplane was between the 2,000- and 3,000-foot runway markers (less than halfway down the runway) when it lifted off and began the right turn. Due to the extensive disintegration of the airplane in the impact sequence, the seating positions for the three occupants could not be determined. One of the occupants was the aircraft owner, who held a private certificate with a single-engine land rating, was known to have previously flown the airplane on contract flights from both the left and right seats. A second pilot was the normal copilot for all previous contract flights; his certificates had been revoked by the FAA. The third occupant held an airline transport pilot certificate and had never flown in the airplane before. Prior to the accident flight, the owner had told an associate that the third occupant was going to fly the airplane on the accident flight. ## Factual narrative 1.1 HISTORY OF FLIGHT On April 17, 2000, about 1035 Pacific daylight time, a Grumman US-2C, N7046U, collided with terrain 1 minute after departure from runway 26 at the Stead Airport, Reno, Nevada. The airplane remained within the boundaries of the airport. Advance Aviation Services, Inc., owned the airplane. They operated it under contract to the Desert Research Institute, a unit of the University and Community College System of Nevada, as a public-use flight. The three crewmembers sustained fatal injuries; the airplane was destroyed. The airplane was on an instrument flight rules (IFR) flight plan, and was to return to Stead after seeding clouds to enhance snowfall in the local mountains. Visual meteorological conditions prevailed. The primary wreckage was at 39 degrees 40.62 minutes north latitude and 119 degrees 52.26 minutes west longitude. Witnesses reported that the airplane began a right turn immediately after departure and appeared to be going slow. One witness reported that he was able to distinguish the individual propeller blades on the right engine, while the left engine propeller blades were indistinguishable. The airplane stopped turning and flew for an estimated 1/4-mile at an altitude of 100 feet. The airplane then continued the right turn at a steep bank angle before disappearing from sight. Then the witness observed a plume of smoke. 1.2 PERSONNEL INFORMATION Due to the destruction of the airplane in the accident sequence, the seating positions of the three crewmembers could not be established with certainty. No one observed the crew board the airplane or their positions as they taxied for takeoff. 1.2.1 Aircraft Owner A review of Federal Aviation Administration (FAA) airman records revealed that the owner held a private pilot certificate with a rating for airplane single-engine land. He did not hold an instrument rating. No personal flight records were located for the owner. The National Transportation Safety Board investigator-in-charge (IIC) obtained the aeronautical experience listed in this report from a review of the airmen records on file in the FAA's Airman and Medical Records Center located in Oklahoma City, Oklahoma. These records indicated a total time of 3,700 hours. A pilot who had flown with the owner the previous year, and the first four flights this year, said that the owner flew in the left seat the first year and in the right seat for the four flights this year. The owner/pilot held a third-class medical certificate that was issued on October 14, 1997. It had the limitation that the pilot must have glasses available for near vision. 1.2.2 Second Pilot The second pilot did not hold a current pilot certificate; his certificate had been revoked by the FAA. Prior to the revocation action, he had held an airline transport pilot (ATP) certificate with a multiengine land rating and an SA-227 type rating. He also had held a commercial pilot certificate with a single-engine land rating. He had held a certified flight instructor certificate with a rating for airplane single-engine land. No personal flight records were located for the second pilot. The IIC obtained the aeronautical experience listed in this report from a review of the airmen records on file in the FAA's Airman and Medical Records Center located in Oklahoma City. These records indicated a total time of 8,170 hours. Another pilot, who had been flying the airplane this year as the primary pilot, was not able to make this flight. The primary pilot had flown about eight or nine flights with this second pilot as his copilot in the right seat. He estimated that the second pilot had 20,000 hours. He estimated that the second pilot had flown with the owner an estimated total time of 20 hours in this airplane. The second pilot held a medical certificate that was issued on January 5, 2000. It had the limitations that the pilot must wear lenses for distant vision and possess glasses for near vision. 1.2.3 Third Pilot The third pilot held an ATP certificate with ratings for airplane single-engine land, multiengine land, and rotorcraft-helicopter. He was type rated in the BH-47, BH-204, BH-206, and BH-212. He held a commercial pilot certificate with an SD-3 type rating. He held a certified flight instructor (CFI) certificate with ratings for airplane single-engine land, multiengine land, and instrument airplane. He also held a CFI certificate with a rating for rotorcraft-helicopter. He was an instrument ground instructor. He held a mechanic certificate with ratings for airframe and powerplant. He held a flight engineer certificate with a rating for turbojet-powered aircraft. He also held an aircraft dispatcher certificate. No personal flight records were located for the third pilot. The IIC obtained the aeronautical experience listed in this report from a review of the airmen records on file in the FAA's Airman and Medical Records Center located in Oklahoma City. These records indicated a total time of 12,000 hours. The third pilot held a second-class medical certificate that was issued on November 3, 1999. It had the limitations that the pilot must wear corrective lenses for near and distant vision. This was the third pilot's first flight in the airplane. He was an acquaintance of the airplane's owner, and had expressed an interest in going on a flight. The owner called him about an hour before the flight, and asked if he would like to go on the flight. The owner had indicated to the primary pilot that he expected this third pilot to fly that morning. A retired FAA inspector, who had flown the S-2 in the Navy, knew the third pilot very well. The inspector said that this pilot would not fly an airplane that he was unfamiliar with, and he certainly would not fly this model without talking to the inspector first. The inspector spoke with the third pilot the day before the accident. The third pilot did not mention that he was going flying in the S-2 or that he had been studying the flight manuals. Public-use aircraft are exempt from Federal Air Regulation (FAR) Part 61, which establishes pilot and medical certification requirements. 1.3 AIRCRAFT INFORMATION The airplane was a Grumman US-2C, serial number 133355. Investigators did not recover logbooks for either the airframe or engines. Public-use aircraft are exempt from FAR 91.7, which describes civil airworthiness requirements. They are also exempt from FAR 91.401 aircraft maintenance requirements. The left engine was a Wright R-1820-82 engine, serial number BL-E 516742. The right engine was a Wright R-1820-82, serial number BLE516824. Maintenance records from a repair facility disclosed that they completed a major repair of the right engine on October 22, 1998. Procedures accomplished included: disassembly and cleaning; magnetic inspection of steel parts; and ultrasonic inspection and replating. They overhauled the magneto and carburetor. They replaced the crankshaft, rods, bearings, pistons, ignition harness, and cylinder stud assemblies. They ran the engine in a test cell for 2.8 hours and estimated that the time since overhaul was 402.8 hours. The NATOPS manual (US Navy equivalent of a Pilot Operating Handbook) described the S-2 systems and operating procedures. Normal takeoff procedure was to release the brakes, advance the throttles to maximum allowable power, lift the nose off between 80 and 85 knots, and fly off at not less than 95 knots. The airplane had a rudder assist system installed. The rudder assist provided additional directional control in the event of a loss of power on either engine. The NATOPS manual specified that the rudder assist switch should be in the ON position for takeoff, landing, and in the event of single-engine operation. Normal rudder trim operated 5 degrees left and right electrically. With rudder assist on, the rudder trim operated 20 degrees left and ## Aircraft - Registration: [N7046U](https://openairdocs.org/deregistered/N7046U-2004-06-02), registration cancelled 2004-06-02, S/N 133355 (OpenAirDocs) - Reported make and model: Grumman US-2C - Registry model: [Grumman US-2C](https://openairdocs.org/model/grumman-us-2c) (registry code 3951013) (OpenAirDocs) - Category: Airplane - Serial number: 133355 - Engines: Wright R-1820-82 reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Public aircraft, Public use - Operator: Desert Research Institute - Registered owner: Advance Aviation Services, Inc. - Airworthiness certificate: Special, Restricted (Special) - Departed: 4SD, RENO, NV - Flight plan: IFR - Airport: 4SD, Reno/Stead, runway 26, 7,608 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; injuries: fatal; commercial, flight instructor, airline transport, flight engineer; airplane ratings: multi-engine land, single-engine land; instrument ratings: helicopter, airplane; medical: class 2, valid medical--w/ waivers/lim; toxicology performed; flight hours: 12,000 total - Other flight crew; age 47; injuries: fatal; commercial, airline transport, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; toxicology performed; flight hours: 8,170 total - Other flight crew; age 66; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, expired; toxicology performed; flight hours: 3,700 total ## Weather - Conditions: Visual (VMC), Day - Visibility: 10 statute miles - Lowest ceiling: 10,000 ft broken - Temperature: 54 °F, dew point 30 °F - Altimeter: 29.00 inHg - Observed at: 4SD ## 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 20000417011199A](https://openairdocs.org/incident/20000417011199A), Apr 17, 2000: Reno, NV, No damage, 3 fatal. (-23) Pilot did not maintain directional control of a/c after takeoff and collied with the ground. 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.