LAX02FA300

NTSB accident investigation · Fairchild SA227-AC · Hawthorne, CA · September 29, 2002

Accident · Serious injuriesField investigationFinal report
Date
September 29, 2002, 09:13 local (16:13 UTC)
Place
Hawthorne, CA
Injuries
1 serious, 20 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N343AEFairchild SA227-AC
Weather
Visual (VMC) · Day
Status
Completed · report October 27, 2005
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20020929028309A
Case key
55798

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-in-command's failure to maintain directional control during the rejected takeoff. The loss of directional control was caused by the crew's failure to follow prescribed pretakeoff and takeoff checklist procedures to ensure the both propellers were out of the start locks. Contributing factors were the failure of the crew to follow normal company procedures during takeoff, the failure of the flightcrew to recognize an abnormal propeller condition during takeoff, and a lack of crew coordination in performing a rejected takeoff.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - on ground/waterTakeoff - roll/run
1 engine
Propeller system/accessories,pitch change mech - not engagedCause
Checklist - not followedPilot in commandCause
Procedures/directives - not complied withFlightcrewCause
Directional control - not maintainedPilot in commandCause
Crew/group coordination - inadequateFlightcrewFactor
On ground/water collision with objectTakeoff - aborted
Aborted takeoff - initiatedPilot in command
Object - building(nonresidential)
Ground loop/swerve - not correctedPilot in commandCause

Analysis

The airplane veered off the runway during a rejected takeoff, overran an airport sign, and impacted a hangar. The captain stated that during the after start checklist he moved the power levers to disengage the start locks on the propellers. Post accident examination found that the left propeller was still in the start lock position, while the right propeller was in the normal operating range. The captain was the pilot flying (PF) and the second-in-command (SIC) was the nonflying pilot (NFP). After receiving their clearance, the PF taxied onto the runway and initiated the takeoff sequence. The SIC did not set and monitor the engine power during takeoff, as required by the company procedures. During the takeoff acceleration when the speed was between 40 and 60 knots, the captain released the nose gear steering control switch as the rudder became aerodynamically effective. When the switch was released, the airplane began immediately veering left due to the asymmetrical thrust between the left and right engine propellers. The PIC did not advise the SIC that he had lost directional control and was aborting the takeoff, as required by company procedures. The distance between where the PIC reported that he began the takeoff roll and where the first tire marks became apparent was about 630 feet, and the distance between where the marks first became apparent and where the airplane's left main landing gear tire marks exited the left side of the runway was about 220 feet. Thereafter, marks (depressions in the dirt) were noted for a 108-foot-long distance in the field located adjacent to the runway. Medium intensity tire tread marks were apparent on the parallel taxiway and the adjacent vehicle service road. These tread marks, over a 332-foot-long distance, led directly to progressively more pronounced marks and rubber transfer, and to the accident airplane's landing gear tires. Based on an examination of tire tracks and skid marks, the PIC did not reject the takeoff until the airplane approached the runway's edge, and was continuing its divergent track away from the runway's centerline. The airplane rolled on the runway through the dirt median and across a taxiway for 850 feet prior to the PIC applying moderate brakes, and evidence of heavier brake application was apparent only a few hundred feet from the impacted hangar. No evidence of preimpact mechanical failures or malfunctions was found with the propeller assemblies, nose wheel steering mechanism, or brakes.

Factual narrative

History of flight

On September 29, 2002, about 0913 Pacific daylight time, a Fairchild SA227-AC, N343AE, veered off the runway during a rejected takeoff and collided with objects at the Hawthorne Municipal Airport, Hawthorne, California. There were 21 persons on board the airplane. Neither of the 2 airline transport certificated pilots was injured; 1 of the 19 passengers was seriously injured, and the other 18 passengers were not injured. The airplane was substantially damaged. The airplane was operated by the Hawthorne-based C.A.T.S. Tours, Inc., d.b.a. Skylink Charter, LLC. An instrument flight rules flight plan was filed, and visual meteorological conditions prevailed. The on-demand air taxi flight with fare-paying passengers was operating under the provisions of 14 CFR Part 135. The flight was originating at the time of the accident as a nonstop flight to the Grand Canyon National Park, Arizona.

The PIC, who was handling the flight controls from the airplane's left seat, verbally reported to the National Transportation Safety Board investigator that no evidence of any mechanical problem was evident during the preflight inspection of the airplane. The engines started normally, and the "after start" checklist was completed.

At 0853, the Hawthorne Airport local air traffic controller (LC) issued N343AE an instrument flight rules clearance to the Grand Canyon, Arizona, the flight's intended destination. About 11 minutes later, at 0904, the LC cleared the airplane to taxi to runway 25.

At 0910:35, the LC issued the airplane a takeoff clearance. According to the PIC, he taxied via Intersection Alpha onto the beginning of the runway near the east side perimeter fence. While taxiing the nose gear steering system operated normally.

The PIC verbally reported to the Safety Board investigator that after he positioned the airplane on runway 25's centerline, he verified that both propellers were off the start locks, "whereupon he positioned the power levers forward to obtain takeoff power. The PIC reported that during the first few seconds of the takeoff roll nothing abnormal was noticed with the operation of the airplane. When the airplane had accelerated between 40 and 60 knots (the speed at which the rudder becomes aerodynamically effective), the second-in-command (SIC) called "airspeed alive," and the PIC released the nose wheel steering button (switch) on the left power lever thus disengaging the nose wheel steering control system that had been functioning normally.

According to the PIC, at this time, he observed that the airplane began veering left of the runway's centerline. The PIC further indicated that he then "initiated an abort" to reject the takeoff by retarding the power levers to the ground idle position and by applying brakes. The airplane continued veering left, so he applied full right rudder and full reverse on the right engine's propeller in an attempt at regaining directional control. This action was followed by application of moderate pressure to the brakes, and finally maximum brakes were applied as the airplane continued veering left and directional control was not regained.

The PIC stated that during the mishap he had not solicited any assistance from the SIC. He did not advise the SIC that he was rejecting the takeoff.

After the airplane veered off the side of the runway it traversed a dirt field (median area) where it overran an airport runway sign. Thereafter, the airplane crossed an active taxiway and a vehicle service road. The airplane came to rest upon impacting and partially penetrating a T-hangar.

Other damage

The airplane overran and destroyed the 1,000-foot runway distance marker sign that was located on the south (left) side of runway 25. The Hawthorne airport manager reported that the sign was constructed with an internal 100-watt transformer that had copper wire windings around its core. The transformer was mounted near the base of the sign. (See photographs of the airport's 2,000-foot runway distance marker sign, which is similar to the accident sign, and its internal transformer.)

Debris from the accident sign was located at and upwind from its mounted location. The transformer, which was separated from the sign, was located on the north side of the runway several hundred feet northwest of the sign. Strands of copper wire were observed dislodged and missing from the transformer's core.

Several T-hangars were impact damaged. Parked inside the hangars, and also damaged, were a Cessna 172, a Piper PA-28-140, a Beech A36, and an automobile. Emergency locator beacons (ELTs) were noted transmitting from two of the three impacted airplanes.

Personnel information

Pilot-in-Command, Certificates & Experience.

The PIC held an airline transport pilot certificate, with a multiengine land rating. He had commercial pilot privileges for single engine land airplanes. His total flight time and flight time as pilot-in-command of a Fairchild SA227, for which he was type-rated, were 2,858 and 696 hours, respectively. During the preceding 90-day period, the pilot had flown the airplane 74 hours.

The pilot held an airframe and powerplant mechanic certificate. Since April 2001, he had been employed as the Director of Maintenance (DM) for the operator, C.A.T.S. Tours, Inc.

Pilot-in-Command, Accident/Incident History.

On January 5, 1997, the pilot (who was serving as the first officer) was involved in an accident while flying a Fairchild SA227 during an air taxi flight to the Grand Canyon for a company called FNG Aviation, d.b.a. Skylink Charters of Santa Monica, California. The Safety Board determined that, in pertinent part, the probable cause of the accident was failure of the pilot(s) to follow the airplane's flight manual checklist procedure. This action resulted in a dual engine flame-out and forced landing.

Second-in-Command, Certificates & Experience.

The SIC held an airline transport pilot certificate, with airplane single-engine and multiengine land ratings. His total flight time and flight time as pilot-in-command of a Fairchild SA227 were 4,462 and 0 hours, respectively. The pilot's total flying experience (copilot time) in the accident model of airplane was 612 hours.

The SIC also held a certified flight instructor (CFI) certificate, for single engine and multiengine airplanes, and instrument airplane.

Second-in-Command, Accident/Incident History.

A review of Federal Aviation Administration (FAA) records indicated the SIC had received a Notice of Disapproval for failure to pass the Commercial Pilot certificate examination in September 1993. He subsequently passed. In November 1993, he received a Notice of Disapproval for failure to pass a CFI certificate examination for airplanes, but he subsequently passed. In 1994, he received a Notice of Disapproval for failure to pass a CFI, instruments, examination, but passed upon reexamination.

The SIC was involved in an August 1997 incident when the landing gear of the airplane he was flying retracted during takeoff. The investigation determined that the gear lever had been placed in the "up" position prior to takeoff and was not detected by the pilot. In December 1997, the SIC twice failed the entire CFI reexamination and received Notices of Disapproval. Thereafter, he voluntarily surrendered his CFI certificate on December 30, 1997.

The SIC obtained new CFI certificates for single and multiengine airplanes in February and March 1998, respectively. Also in 1998, while he was flying for an air carrier, he hit the wing tip of another airplane while taxiing, and his employment was terminated by the company. After working for other air carriers, he commenced employment with C.A.T.S. Tours, Inc., in April 2001.

Director of Operations and History of Companies.

The Director of Operators (DO) of C.A.T.S. Tours, Inc., d.b.a. Skylink Charter, was also

Aircraft

Registration
N343AE
Reported as
Fairchild SA227-AC
Category
Airplane
Serial number
AC 554
Airframe hours
30,660
Engine
Garrett TPE331-11U, 1,000 horsepower, turbo prop
Damage
Substantial damage
Flight
Part 135
Operator
C.A.T.S. Tours, Inc., doing business as Skylink Charter, LLC
Registered owner
Air Demand, LLC
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · September 1, 2002 · 23 hours before
Departed
HHR · Hawthorne, CA
Destination
GCN · Grand Canyon, AZ
Flight plan
IFR
Airport
HAW · Hawthorne, runway 25, 4,956 × 100 ft, concrete

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
41
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
May 1, 2002
Seat
Left
Toxicology
Performed
Flight hours
2,858 total · 2,212 in this make and model · 1,182 as pilot in command · 81 in the last 90 days · 34 in the last 30 days · 4 in the last 24 hours
Role
Co-pilot
Age
34
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Right
Toxicology
Performed
Flight hours
4,462 total · 612 in this make and model · 3,756 as pilot in command · 215 in the last 90 days · 52 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
5,000 ft broken
Temperature
64 °F, dew point 57 °F
Altimeter
29.96 inHg
Observed at
HHR

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.