# NTSB LAX02FA028: Cessna 340A, N2RR, Santa Monica, CA, November 14, 2001 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 13, 2001, 18:36 local (Nov 14, 2001, 02:36 UTC) - Place: Santa Monica, CA - Coordinates: 34.009952, -118.460884 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.0100&lon=-118.4609&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report April 23, 2003 - Report: Approved by Office Director - Parties: Cessna Aircraft Company, Teledyne Continental Motors, FAA Flight Stnds Dist Office - NTSB case key (mKey): 53767 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX02FA028 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/53767/pdf - Page: https://openairdocs.org/ntsb/LAX02FA028 ## Probable cause The pilot's failure to remove the control gust lock prior to takeoff and his failure to abort the takeoff with sufficient runway remaining to stop the airplane on the runway. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Overrun, takeoff - aborted - aircraft preflight - inadequate, pilot in command - removal of control/gust lock(s) - not performed, pilot in command (cause) - aborted takeoff - delayed, pilot in command (cause) - On ground/water collision with object, takeoff - aborted ## Analysis During an aborted nighttime takeoff, the airplane continued off the end of the 4,987-foot-long runway, vaulted an embankment, and impacted a guardrail on an airport service road 30 feet below. According to the manufacturer's pilot operating handbook, the takeoff distance required for the ambient conditions was 1,620 feet and the accelerate-stop distance was 2,945 feet. Several witnesses reported observing the airplane traveling along the runway at an unusually high speed, with normal engine sound, and without becoming airborne; followed by an abrupt reduction in engine power and the sound of screeching tires. Skid marks were present on the last 1,000 feet of the runway. In the wreckage, the gust lock/control lock was found engaged in the pilot's control column. ## Factual narrative HISTORY OF FLIGHT On November 13, 2001, at 1836 Pacific standard time, a Cessna 340A, N2RR, continued off the end of runway 21, vaulted an embankment, and came to rest on an airport service road during an aborted takeoff at Santa Monica Municipal airport, California. The private pilot and one passenger were fatally injured and the airplane was destroyed. Night, visual meteorological conditions prevailed and no flight plan was filed for the personal flight that was operated by the owner under 14 CFR Part 91. The flight was destined for Van Nuys California. A private pilot observed the accident from the Justice Aviation ramp, which is on the south side of the airport about the 3,500-foot point along runway 21 [Note: Runway 21 is 4,987 feet long and 150 feet wide, grooved asphalt]. He said his attention was attracted to the airplane because he was accustomed to seeing airplanes pass that point on the runway at 100 - 200 feet above the runway, and this airplane was very low or on the runway (it was dark) and traveling very fast; he estimated 120 knots. He described the engine sound as normal. As the airplane passed his position, engine power was reduced to idle and he started hearing tire skidding sound. He thought perhaps one engine had failed and the pilot was aborting the takeoff. The skidding sound continued for a period of time and there were two distinct "pops," which he assumed were the tires "blowing out." The airplane continued skidding, went off the end of the runway, and he then saw the fire. A flight instructor at the same location said his attention was attracted to the airplane as it passed because it was traveling very fast, about 120 knots, and was either on the runway or 10 - 20 feet above it. It was dark and the engines sounded normal. As the airplane passed abeam his position the engine power was abruptly reduced ("an engine cut") and he thought the pilot had had an engine failure and was aborting. He then heard a tire skidding sound during which there were two "pop" sounds and then he saw the fire/explosion. A third witness, who was not a pilot, witnessed the accident from the same location while waiting for a friend. His attention was drawn to the accident airplane because; whereas most planes were flying past him well into the air, the accident plane never left the ground. It went by him going "real fast, fast enough to fly." He then heard the tires "screeching" and saw the plane go off the end of the runway. He doesn't recall any abnormal sound from the engines and couldn't recall if the engine sound ceased when the tire screeching started. A corporate pilot who held an airline transport pilot certificate observed the airplane during its takeoff roll from his position at the middle of the ramp at Supermarine Aviation on the north side of the runway, approximately at the runway mid-length point. He reported having a great deal of general aviation experience and was familiar with the Cessna 340 and the engine sound it normally makes. His attention was attracted to the airplane as it went past his position because it was traveling very fast on the runway and was not airborne, as he knew a Cessna 340 normally should be. The engine sound was normal; smooth and synchronized. He commented to his first officer, who was standing next to him, that the airplane must be "really heavy" to have been still on the runway at that speed. Their view of the airplane became blocked by a hangar to the right (west) of their position and he said to his first officer "I don't think this is right." They walked together to the taxiway edge of the ramp and looked to the west in time to see the flash of the fire and hear the muffled explosion. He ran back to his airplane and got his flight attendant, who was a nurse, and together they went to the accident site but were unable to render any aid. A flight instructor, who was in the run-up area with a student at the time of the accident, reported that as he and the student taxied to the run-up area they passed the accident aircraft that was in a parking area for the Typhoon restaurant. The restaurant and the parking area are about 1,500 feet from the threshold end of runway 21. As they taxied past the Cessna 340 all of its lights were on, including strobe lights, and he commented to his student about the matter of courtesy to other pilots when using lighting on the ground at night and added that he thought the pilot was in a rush. As he and his student were in the run-up area completing their preflight checks, the Cessna 340 taxied past in front of them and, without stopping in the run-up area, taxied directly up to the runway hold short line. He again commented to his student that the pilot "must be in a hurry." He was not certain how long the Cessna 340 held at the runway before being cleared for takeoff. The departure was full length on the runway. PERSONNEL INFORMATION The pilot's logbook was not located after the accident. On the pilot's application for medical certificate, dated April 19, 2001, he reported having "6,200+" hours to date, total pilot time, and "90+" hours in the previous 6 months. A mechanic and pilot who knew the pilot and had flown with him in the past said his piloting skills were "impeccable" and that he maintained his airplanes "immaculately" nothing was spared. He added that, like some executive/pilots, the pilot was sometimes "in a hurry" when he came to the airport to go flying. COMMUNICATIONS The Safety Board investigator listened to a re-recording of radio communications between the pilot and Santa Monica ground control and local control (tower) provided by the Federal Aviation Administration (FAA) Southwest Region Quality Assurance Office. At 1833, the pilot transmitted "good evening santa monica twin Cessna two romeo romeo at the admin administration building with hotel taxi for takeoff please." Nine seconds later, the ground controller cleared the aircraft to taxi to runway 21. Two-minutes and 2 seconds after the controller cleared the airplane to taxi, the pilot transmitted on the local control position (tower) frequency: "van nuys excuse me uh santa monica twin Cessna two double R is ready to go straight out please right turn at the shoreline." Thirteen seconds later the local controller cleared the airplane to taxi into position and hold on runway 21, and, an additional 13 seconds later, cleared the airplane for takeoff. AIRPORT INFORMATION The distance from the parking location at the administration building to the runway 21 threshold is approximately 1,500 - 1,700 feet. WRECKAGE AND IMPACT INFORMATION The accident site was on the western end of the airport, within the airport perimeter boundaries. The airplane skidded off the end of the runway 21, vaulted a 30-foot embankment, and came to rest on an airport service road that was aligned north-south and passed about 300-feet west of the end of runway 21. The accident location on the service road was approximately 100 feet north of the runway extended centerline. A guardrail on the western (far) edge of the service road was deformed about 1-foot in proximity of the wreckage and the concrete curb beneath the guardrail was damaged over about an 8-inch area. The curb damage was accompanied by a black smear mark on the concrete, which resembled the propeller deice boot material. The entire airplane was present at the accident site and the airplane was destroyed by impact and fire. At the accident site the airplane's (fire damaged) flight control lock was found with the pin engaged through the mating hole of the pilot's control column. The flag on the control lock was absent. As found in the wreckage, the control lock had been installed from right-to-left; but with the diagonal leg passing over the top of the control column tube and extending upward and to the left. On the southwestern end of the runway surface above where the wreckage ## Aircraft - Registration: [N2RR](https://openairdocs.org/deregistered/N2RR-2011-06-13), registration cancelled 2011-06-13, S/N 340A0643, built 1978 (OpenAirDocs) - Reported make and model: Cessna 340A - Registry model: [Cessna 340A](https://openairdocs.org/model/cessna-340a) (registry code 2076405) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 340A0643 - Airframe hours: 1036 - Engines: Continental TSIO-520-NB 310 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Richard C. Runyon - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 27, 2000, 68 hours before - Departed: SMO, Santa Monica, CA - Destination: VNY, Van Nuys, CA - Airport: SMO, Santa Monica Municipal, runway 21, 4,987 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: fatal; private; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; toxicology performed; flight hours: 6,200 total, 45 in the last 90 days ## Weather - Conditions: Visual (VMC), Night - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 59 °F, dew point 52 °F - Altimeter: 30.10 inHg - Observed at: SMO, 1 nm away ## 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 20011113031319A](https://openairdocs.org/incident/20011113031319A), Nov 13, 2001: Cessna 340A, Santa Monica, CA, No damage, 2 fatal. (-23) During takeoff pilot was unable to pitch up on account flight controls lock was installed in control column. 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.