# NTSB LAX01LA019: Beech 300, N398DE, Concord, CA, October 19, 2000 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: October 19, 2000, 15:38 local (22:38 UTC) - Place: Concord, CA - Coordinates: 37.989723, -122.056945 - Nearby events: https://openairdocs.org/map.md?lat=37.9897&lon=-122.0569&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor; on the ground: 1 serious - Status: Completed, report November 25, 2003 - Report: Approved by Office Director - Parties: Raytheon Aircraft Company, Hartzell Propeller Inc., Federal Aviation Administration - NTSB case key (mKey): 50502 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX01LA019 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/50502/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=50502 - Page: https://openairdocs.org/ntsb/LAX01LA019 ## Probable cause the pilot's delayed decision to abort the takeoff and his failure to utilize the propeller's reverse pitch function. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Overrun, takeoff - aborted - aborted takeoff - delayed, pilot in command (cause) - reversers - not used, pilot in command (cause) - On ground/water collision with object, takeoff - aborted - object - fence - object - vehicle ## Analysis The twin turboprop airplane overran the runway, impacted two fences, and an occupied automobile after the airline transport pilot attempted to abort a takeoff. The pilot performed a rolling takeoff and was paying close attention to balancing the engine power and keeping runway centerline alignment. As the airplane accelerated, the pilot set the power above 80 percent and began an instrument scan. He then noted the airspeed indicator was reading zero with the needle resting on the peg. After a moment's hesitation, the pilot attempted to abort the takeoff by reducing the power levers to flight idle, and subsequently over the gate to ground fine. He reported to the FAA that he did not place the power controls into the reverse position. Air traffic controllers reported they observed the airplane with its nose wheel off of the ground approximately 3/4 of the way down the 4,602-foot long runway. The aircraft's left and right pitot/static systems were examined and tested after the accident, and no anomalies were noted. The pilot obtained verbal training on rejected/aborted takeoffs for the accident airplane. He obtained his type rating and 14 CFR 135 check-out in the accident airplane approximately 1 month prior to the accident. The pilot had accumulated a total of 10,867.5 hours of flight time, of which 34.7 hours were accumulated in the accident aircraft make and model. The pilot reported his total pilot-in-command flight time in the accident aircraft make and model as 20 hours, all of which were accumulated within the preceding 30 days of the accident. Examination of the airplane, the flight instruments and the pitot/static system found no explanation for the pilot reported lack of airspeed reading. The brakes were found to be fully functional. Review of the performance charts for the airplane disclosed that for the weight and ambient conditions of the takeoff, the airplane required 4,100 feet for an accelerate-stop distance; the runway was 4,602 feet long. ## Factual narrative HISTORY OF FLIGHT On October 19, 2000, at 1538 Pacific daylight time, a Beech 300 twin-engine airplane, N398DE, overran the runway and struck an automobile during an aborted takeoff at the Buchanan Field, Concord, California. The airplane sustained substantial damage; however, the airline transport pilot sustained minor injuries. The driver, who was the sole occupant of the automobile, received serious injuries. The airplane was registered to King Air Charter, Danville, California, and was operated by AeroSmith Aviation, Inc., Concord, as a positioning flight under 14 CFR Part 91 when the accident occurred. The flight was originating at the time of the accident and was destined for San Jose, California. Visual meteorological conditions prevailed, and a flight plan was not filed. According to the pilot's written statement, he performed a rolling takeoff on runway 32R and was paying close attention to balancing the engine power and keeping runway centerline alignment. As the airplane accelerated, the pilot set the engine power above 80 percent and began an instrument scan. He then noted the airspeed indicator was reading zero with the needle resting on the peg. The pilot looked back at the power (torque) gauges, and then back to the airspeed indicator. He then attempted to abort the takeoff by reducing the power levers to idle, then to reverse, and by applying the brakes. The airplane skidded off the end of the runway, through a chain link perimeter fence, and struck an automobile that was traveling on the perimeter road. The airplane continued across the road, coming to rest on second chain link fence that bordered California State Highway 4. After coming to a stop, the pilot moved the fuel control levers to fuel cutoff, closed the engine firewall fuel shutoff valves, and moved the gang bar down to shutoff all electrical power. He then deplaned through the aft main cabin door. Federal Aviaiton Administration (FAA) inspectors, who responded to the accident site, interviewed the Concord Air Traffic Control Tower controllers. The air traffic controllers observed the airplane with its nose wheel off of the ground between the intersections of runways 32R and 19R and taxiway E, which is approximately 3/4 of the way down the 4,602-foot-long runway. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate with an airplane multiengine land rating and type ratings in BE-300 and BA-3100 aircraft. He also held a commercial pilot certificate with an airplane single engine land rating. The pilot was issued a first-class medical certificate with no limitations on September 27, 2000. The pilot underwent "Beechcraft Super King Air 300 Differences Ground & Flight Training" on August 23-26, 1999. Review of the pilot's training records revealed he obtained discussion training on rejected/aborted takeoffs. The pilot obtained the BE-300 type rating on September 17, 2000. According to the Airmen Competency/Proficiency Check Form for FAR 135 operations, dated September 18, 2000, the pilot received a satisfactory grade for Rejected Takeoffs. The pilot's FAR 135 flight training with AeroSmith Aviation included the following aircraft: BE-F90 April 27, 1999 BE-200B May 14, 1999 BE-200 November 30, 1999 BE-F90 May 30, 2000 BE-300 September 18, 2000 FAA inspectors reported the pilot had only received discussion training for high speed takeoff aborts in both the 200 and 300 aircraft. The high speed aborts were never practiced or demonstrated during the pilot's training and checkouts. According to the Pilot/Operator Aircraft Accident Report, the pilot had accumulated a total of 10,867.5 hours of flight time, of which 34.7 hours were accumulated in the accident aircraft make and model. The pilot listed his total pilot-in-command flight time in a 300 as 20 hours, all of which were accumulated within the preceding 30 days of the accident. AIRCRAFT INFORMATION The Beechcraft Super King Air 300 power levers have three possible ranges: 1. the flight range, from full power to idle (flight idle) position; 2. ground fine (ground idle); and 3. reverse. The power levers can move uninhibited from maximum power to idle. The levers must then be lifted over a detent to place the power levers to the ground fine position. The levers must be lifted again over another detent to place the power levers to the reverse position. The power lever columns have two LIFT placards located adjacent to the detent positions. For the model 200, the power levers have only the flight range and reverse, which is achieved by lifting the lever once at the idle stop over a gate. There were two airspeed indicators installed in the aircraft; one on the pilot instrument panel, and one on the co-pilot instrument panel. The aircraft was also equipped with two entirely independent pitot/static systems. The aircraft's last altimeter and static system inspection was performed on November 17, 1998. The pilot fueled the aircraft prior to departure, providing 2,400 pounds of fuel at the time of takeoff. The approximate takeoff weight at the time of departure was 11,192 pounds. METEOROLOGICAL INFORMATION The weather conditions at the time of the accident were winds from 310 degrees at 7 knots; temperature 26 degrees Celsius; dew point 8 degrees Celsius; and altimeter setting of 29.98 inches of mercury. WRECKAGE AND IMPACT INFORMATION Tire skid marks, which led to the aircraft's final resting place, were noted in the runway surface approximately 203 feet prior to the runway end. The tire marks, from start to end, measured 699 feet in length and were noted on the runway, grass, road, and curbs. The airplane's nose landing gear had separated from the aircraft at its lower strut was found laying near the automobile. The left landing gear collapsed; however, it remained attached to the aircraft. The right main landing gear remained upright and attached to the airplane. Some of the landing gear tires displayed flat spots, some of which had chord showing through. The brake linings were inspected and found to be within operational limits. No leaks were noted in any of the brake lines. The gust lock pin assembly was found loose in the cockpit. The gust lock pin hole in the control column did exhibit some scoring on its forward edge; however, it was not elongated. The right pitot tube was found stuck in the chain link fence and was removed by airport personnel and was given to FAA inspectors. The left pitot tube was removed by FAA inspectors, and both pitot tubes were sent to the National Transportation Safety Board Materials Laboratory for further examination. The propellers were examined by a manufacturer's representative. Prior to disassembly, both propellers were visually at a reverse pitch position; however, the representative indicated "this position is explainable by impact damage and is not necessarily a pre-impact position." One blade from each propeller had been turned about 90 degrees toward low/reverse pitch, and one blade from each propeller was bent aft. According to the representative, the spinners did not display impact damage that could be correlated to a propeller blade angle. The left and right propeller blades (labeled L 1-4 and R 1-4) were examined. Blade L1 was bent aft 90 degrees and displayed scoring on the blade face and tip damage. Blade L2 was bent aft 20 degrees and displayed scoring on the leading edge and camber side. Blade L3 displayed impact marks on the camber side and the tip was twisted and torn off. Blade L4 was bent aft 45 degrees. All four of the left propeller blades were twisted toward low pitch. Blade R1 was bent aft 90 degrees and displayed leading and trailing edge damage. Blade R2 was undamaged. Blade R3 was bent aft slightly and displayed leading edge, trailing edge, and tip damage. Blade R4 was bent aft 45 degrees and displayed lead ## Aircraft - Registration: [N398DE](https://openairdocs.org/deregistered/N398DE-2003-04-24), registration cancelled 2003-04-24, S/N FA109, built 1986 (OpenAirDocs) - Reported make and model: Beech 300 (BE-300) - Registry model: [Beech 300](https://openairdocs.org/model/beech-300) (registry code 1152930) (OpenAirDocs) - Registry engine: [Pratt & Whitney PT6A series](https://openairdocs.org/engine/pratt-whitney-pt6a-series) (registry code 52032, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: FA-109 - Airframe hours: 3801.2 - Engines: Pratt & Whitney PT6A-60A 1050 horsepower turbo prop; Pratt & Whitney PT6A-60A 1050 horsepower turbo prop - Damage: Substantial damage - Flight: Positioning, Part 91 - Operator: AeroSmith Aviation, Inc., doing business as AeroSmith Aviation, Inc. - Registered owner: King Air Charter - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, September 22, 2000, 47.3 hours before - Departed: CCR, Concord, CA - Destination: SJC, San Jose - Airport: CCR, Buchanan Field, runway 32R, 4,601 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; injuries: minor; flight instructor, commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review September 17, 2000; seat: left; flight hours: 10,868 total, 35 in this make and model, 5,905 as pilot in command, 212 in the last 90 days, 46 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 46 °F - Altimeter: 29.97 inHg - Observed at: CCR ## 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 20001019038809A](https://openairdocs.org/incident/20001019038809A), Oct 19, 2000: Beech 300BEECH, Concord, CA, No damage. (-23) No narrative ## Docket (12 files) The files NTSB released with the investigation on September 26, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=50502. 2.5 MB in all. - Materials Laboratory 15 - Factual Report 01-095 pitot tubes (item 1, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40175119&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report%2001-095%20pitot%20tubes-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 422 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40465828&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Witness Statement (item 3, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40465829&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF - Reports from Federal Agencies, FAA (item 4, .PDF, 315 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40465830&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies,%20FAA-Master.PDF - Reports from Federal Agencies, FAA Pilot Interviews (item 5, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40465831&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies,%20FAA%20Pilot%20Interviews-Master.PDF - Reports from Parties to the Investigation, Raytheon (item 6, .PDF, 202 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40465832&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation,%20Raytheon-Master.PDF - Reports from Parties to the Investigation; Raytheon Follow-up Report (item 7, .PDF, 200 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40465833&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation;%20Raytheon%20Follow-up%20Report-Master.PDF - Reports from Parties to the Investigation; Hartzell Report (item 8, .PDF, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184424&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation;%20Hartzell%20Report-Master.PDF - Other Pertinent Forms and Reports; Pilot Training and 135 Checkouts (item 9, .PDF, 565 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40465835&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports;%20Pilot%20Training%20and%20135%20Checkouts-Master.PDF - Other Pertinent Forms and Reports; Stearling Static Check (item 10, .PDF, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40465836&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports;%20Stearling%20Static%20Check-Master.PDF - Materials Laboratory 15 - Factual Report of Group Chairman (item 11, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184433&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Other Pertinent Forms and Reports; Maintenance Records (item 12, .PDF, 197 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40465834&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports;%20Maintenance%20Records-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.