# NTSB LAX03LA083: Beech 76, N5400M, Truckee, CA, January 17, 2003 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: January 17, 2003, 10:30 local (18:30 UTC) - Place: Truckee, CA - Coordinates: 39.322223, -120.143608 - Nearby events: https://openairdocs.org/map.md?lat=39.3222&lon=-120.1436&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report December 28, 2004 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 56447 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX03LA083 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56447/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56447 - Page: https://openairdocs.org/ntsb/LAX03LA083 ## Probable cause failure of the CFI to ensure that the pilot under instruction adequately understood the engine out procedure during the preflight planning phase of the flight; failure of the pilot under instruction to obtain/maintain directional control; and the inadequate supervision and delayed remedial action of the CFI during the engine out procedure. The pilot under instruction's misunderstanding of the engine out procedure was a factor in the accident. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - on ground/water, takeoff - roll/run - engine shutdown - intentional, pilot in command(cfi) - 1 engine - preflight planning/preparation - not understood, dual student (cause) - procedures/directives - not understood, dual student (contributing factor) - directional control - not obtained/maintained, dual student (cause) - supervision - inadequate, pilot in command(cfi) (cause) - remedial action - delayed, pilot in command(cfi) (cause) - On ground/water encounter with terrain/water, takeoff - roll/run - terrain condition - snowbank ## Analysis The airplane veered off the runway and struck a snow bank off the left side of the pavement. The CFI briefed on an engine out procedure prior to takeoff and told the student he was going to fail the left engine. However, the pilot under instruction (PUI) did not fully understand the procedure. He believed that the engine failure would happen when they were in the air and not on the ground. During the takeoff roll, the CFI simulated the engine out by pulling the left mixture. However, the PUI did not pull the throttles to idle as briefed. He was surprised when the airplane started to veer to the left during the takeoff roll. He fixated on the rudder controls, and did not reduce engine power on the right engine. Both pilots stated that there were no mechanical anomalies with the airplane. ## Factual narrative On January 17, 2003, at 1030 Pacific standard time, a Beech 76, N5400M, collided with a snow bank during takeoff from the Tahoe-Truckee Airport (TRK), Truckee, California. The Palo Alto Flying Club was operating the rental airplane under the provisions of 14 CFR Part 91. The airplane sustained substantial damage. The certified flight instructor (CFI) and the private pilot under instruction PUI) were not injured. The cross-country instructional flight departed the Palo Alto Airport of Santa Clara County (PAO), Palo Alto, California, at 0845, en route to TRK. Visual meteorological conditions prevailed, and no flight plan had been filed. On February 5, 2003 the incident was upgraded to an accident after verification that the airplane had been substantially damaged. According to the CFI, the purpose of the flight was to practice maneuvers. At TRK he briefed the PUI on the procedures for a simulated engine failure on takeoff, which included recovery procedures. The PUI aligned the airplane with the runway centerline. The PUI engaged the brakes, added partial power, and then full power. The PUI released the brakes, and the CFI leaned the left mixture to idle cut off. The CFI stated that the airplane yawed to the left, and the PUI "failed to pull the throttles to idle." The airplane collided with the snow bank. The CFI reported that prior to colliding with the snow bank, the right mixture was to idle cut off. According to the PUI, they had conducted engine out procedures on the training flight from PAO. After landing the CFI suggested that, since the runway was 7,000 feet long, it would be a good airport to practice engine out procedures during the takeoff roll. There would be plenty of room to stop. The PUI stated that the CFI explained the "procedure of reducing power, using rudder to control direction, and stated that he would fail the left engine." The PUI indicated that his understanding was that the "failure" would occur after they "were underway" in the air. He was surprised when the airplane veered to the left immediately after he started to add power. He was too slow in "reducing power, [and] fixated on rudder control." Both pilots reported that there were no mechanical anomalies with the airplane. ## Aircraft - Registration: N5400M (not matched to a registry record) - Reported make and model: Beech 76 - Category: Airplane - Serial number: ME-30 - Airframe hours: 690 - Engines: Lycoming O-360 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Palo Alto Flying Club - Registered owner: Jerry Hoffman - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 1, 2002, 45 hours before - Departed: PAO, PALO ALTO, CA - Destination: TRK, TRUCKEE, CA - Airport: TRK, Truckee-Tahoe, runway 28, 7,000 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 40; injuries: none; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; last flight review February 1, 2002; seat: right; flight hours: 1,775 total, 75 in this make and model, 1,555 as pilot in command, 95 in the last 90 days, 30 in the last 30 days - Student pilot; age 59; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; last flight review January 17, 2001; seat: left; flight hours: 710 total, 9 in this make and model, 632 as pilot in command, 15 in the last 90 days, 9 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 30,000 ft broken - Temperature: 37 °F, dew point 28 °F - Altimeter: 30.45 inHg - Observed at: RNO, 20 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 20030117001399A](https://openairdocs.org/incident/20030117001399A), Jan 17, 2003: Beech 76, Truckee, CA, Substantial damage. (.19) On January 17, 2003, about 1015 pacific standard time, a Beech 76, N5400M, collided with a snow bank during takeoff at Truckee, California. The palo alto… ## Docket (2 files) The files NTSB released with the investigation on November 5, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56447. 706 KB in all. - Pilot - CFI Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 320 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442931&FileExtension=.PDF&FileName=Pilot%20-%20CFI%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot - Student Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 385 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442932&FileExtension=.PDF&FileName=Pilot%20-%20Student%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.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.