LAX96FA228

NTSB accident investigation · British Aerospace BA-3100/3201 · San Luis Obispo, CA · June 6, 1996

Accident · No injuriesField investigationFinal report
Date
June 6, 1996, 05:58 local (12:58 UTC)
Place
San Luis Obispo, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N926AEBritish Aerospace BA-3100/3201
Weather
Instrument (IMC) · Day
Status
Completed · report March 31, 1998
Report
Approved by Office Director
FAA report
19960606012959A
Case key
29280

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 flight crew's loss of directional control resulting from an attempted takeoff with the left propeller on the start lock. Factors in the accident were: the lack of cockpit caution/warning system/lights available to verify that the propellers are out of the start locks; and the captain's location in the right seat without access to the nosewheel steering tiller.

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
Propeller - not setFlightcrewCause
Caution/warning system/light(s) - not availableManufacturerFactor
Acft/equip,inadequate designManufacturerFactor
Directional control - not maintainedFlightcrewCause
Nosewheel steering - not availablePilot in commandFactor

Analysis

The first officer, who was 6 months past due for a proficiency check in the aircraft, was in the left seat for the ferry flight and applied power on takeoff. At 40 knots he transitioned from tiller to rudder steering while the captain was setting takeoff power. Moments later the crew felt the aircraft jerk to the left. The captain took the controls and brought both power levers back to flight idle and then into reverse. The captain attempted to control the aircraft but did not have access to the tiller from his position in the aircraft. Full application of rudder and differential braking could not bring the aircraft under control as it veered off the left side of the runway, then back to the right edge. Following the accident, the nose wheel steering, brakes, and propellers were functionally tested in accordance with the aircraft maintenance manuals, with no discrepancies noted. The FDR showed that the airspeed peaked at 58 knots. The rudder effectiveness increases incrementally from 40 knots IAS to full authority at 70 knots. A CVR tape sound spectrum analysis revealed that the left engine was in the start lock position during the takeoff. Normal procedure after engine start is to bring the props into reverse momentarily to bring them out of the start locks. There is no cockpit indicator for the position of the propellers relative to the start locks.

Factual narrative

History of flight

On June 6, 1996, at 0558 hours Pacific daylight time, a British Aerospace Jetstream BA-3201, N926AE, ran off the runway while on takeoff from San Luis Obispo County-Mc Cesney Field, San Luis Obispo, California. The aircraft sustained substantial damage; however; the certificated airline transport pilot and copilot were not injured. The aircraft was being operated as a ferry flight by the JSX Capital Corporation, Washington, D.C., under 14 CFR Part 91 when the accident occurred. The flight was originating at the time on an IFR flight plan to Kingman, Arizona. Instrument meteorological conditions prevailed.

The captain, who was in the right seat, reported that he and the first officer completed the cockpit setup, the before start check, the start engine check, and the after start check. He did not report any abnormalities or interruptions during the procedures. The after start checklist directs that the pilot take the propellers off the start locks by individually pulling each power lever into reverse until the crew sees a rise in torque on the torque meter. There is no other cockpit indication as to the position of the propellers relative to the start locks. (Excerpts from the Jetstream Series 3200 Flight Manual are appended to this report.)

The crew requested their IFR clearance and release from Los Angeles center. They were cleared to Kingman via the Avila 3 standard instrument departure (SID). Ground personnel pulled the chocks and the ground power unit (GPU) and the aircraft prepared to taxi. The first officer reported receiving an emergency briefing from the captain.

Both crewmembers reported checking the aircraft brakes and verifying hydraulic pressure gauges from the respective positions. After taxiing to the departure end of runway 11, the crew completed the before takeoff check, made a visual check for traffic, and then made an advisory call over the tower frequency. Following a check for possible air traffic in the vicinity, the aircraft taxied onto the runway.

The first officer, who was on the controls, applied power as the takeoff roll began. The captain set the power, matching both engines at 100 percent N1. As the aircraft accelerated, the airspeed indicator began to register as the airspeed reached about 40 knots. At this point, the captain told the first officer that he could transition from the tiller to the rudder. The captain saw the first officer's hand come off the tiller as he was making a final power adjustment and moments later he felt the aircraft jerk to the left. He saw the aircraft begin a rapidly increasing left turn and felt the first officer applying full right rudder. The first officer reported that he had rudder authority prior when he took his hand off the tiller, but subsequently lost directional control after feeling the jerk. The aircraft manufacturer recommends that the pilot keep his hand on the tiller until reaching 70 knots.

The captain took the controls and began to abort the takeoff. He brought both power levers back to flight idle and then into reverse as the aircraft continued veering left. He applied full right rudder and right brake. By the time the turn stopped, the aircraft was already headed off the left side of the runway. The captain was unable to steer the aircraft since the tiller is positioned to be reached from the left seat. He remained on the controls as the aircraft left main gear rolled off the left side of the runway. He felt another jolt and noticed the aircraft slowing as left gear encountered the freshly plowed, soft terrain next to the runway. The blades of the No. 1 propeller contacted the ground as the left gear sank into the soft dirt.

As the aircraft continued, it began an uncommanded right turn and rolled back onto the runway. The captain attempted to control the aircraft but it continued in a right turn. The captain then put both propellers into feather and the aircraft coasted to a stop about 5 feet from the right edge of the runway. At this point he reported he had no control over the aircraft steering or brakes. He shut down both engines and notified center that he was disabled on the runway.

The captain stated that he neither saw nor heard any cockpit indications of a problem. He reported that he thought he had lost braking when he first took control of the aircraft because the aircraft did not respond. He also thought he had lost directional control when he applied full right rudder with no apparent effect. The first officer said he did not attempt to use the tiller after relinquishing the controls to the captain. He reported that he did not experience any steering or braking problems during taxi, nor did he notice any control binding or feedback. The aircraft manufacturer reported that rudder effectiveness increases incrementally beginning about 40 knots airspeed with full authority achieved by approximately 70 knots.

Personnel information

The captain and first officer were properly certificated in accordance with existing Federal Air Regulations (FARs). Both crewmembers reported that they were in good health at the time of the accident.

The captain had been hired by American Eagle on October 14, 1986. In addition to an ATP certificate he is type rated in the BA-3100, SA-227, and SF-340. He received his initial type rating in the BA-3100 on February 24, 1992. The captain's position with American Eagle is as a check airman and training pilot. His last proficiency check was accomplished on October 23, 1995.

The first officer was hired by American Eagle on November 1, 1987. In addition to his ATP certificate he is type rated in the SA-227 and SF-340. A type rating in the BA-3100 is not required for the performance of copilot duties. After retiring from American Eagle on May 15, 1995, the first officer continued his association with the company as a contract consultant. His last proficiency check was accomplished in January, 1995.

Aircraft information

The captain reported that he had flown the aircraft on two maintenance test flights in which the No. 2 engine had failed to meet the flight idle torque differential parameters. Trouble shooting revealed that the torque was not adjusted properly. An adjustment was made, but on the second flight the engine still was unable to achieve the proper torque. After maintenance personnel were unable to resolve the problem the No. 2 engine was changed on May 4, 1996.

The aircraft, which had been leased to American Eagle, had, according to maintenance personnel, completed a service check in accordance with the JS3200 Maintenance Schedule on June 5, 1996. The service check was performed as a condition of the lease and was required to be completed before ferrying the aircraft back to its corporate owner in Kingman, Arizona.

As a condition of acceptance, the hydraulic fluid used by American Eagle, MIL-H-83282 was replaced with MIL-H-5606 in accordance with service bulletin No. 29-JK 12078 revision No. 1.

Airport information

At the time of the accident a NOTAM was in effect for McChesney Field. The airport was scheduled to be closed from 2345 till 0530 on the morning of the accident for construction. The construction involved plowing the terrain on the left side of runway 11. (A copy of the NOTAM is appended to this report.)

Flight recorders

The flight data recorder (FDR) and cockpit voice recorder (CVR) were secured and removed for readout. The FDR was read by the Air Accidents Investigation Branch (AAIB) of the United Kingdom on July 17, 1996. The readout showed that the airspeed had peaked at 58 knots and the heading had varied from 95 to 170 degrees. (The FDR printout is appended to this report.)

The CVR tape was submitted to the National Transportation Safety Board for a sound spectrum analysis. The examination revealed that one of the engines was at 105-106 percent, while the other engine was at 99-101 pe

Aircraft

Registration
N926AE
Reported as
British Aerospace BA-3100/3201 (BA-3100/32)
Category
Airplane
Serial number
926
Airframe hours
8,464
Engine
Garrett TPE-331-12WHR, 1,020 horsepower, turbo prop
Damage
Substantial damage
Flight
Positioning · Part 91
Operator
Kenneth A. Denyer, doing business as Jsx Capital Corporation
Registered owner
First Security Bank Of Utah
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · March 6, 1996 · 122 hours before
Departed
SBP
Destination
IGM · Kingman, AZ
Flight plan
IFR
Airport
SBP · Mc Chesney Field, runway 11, 4,799 × 150 ft, asphalt

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
42
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Flight hours
9,000 total · 2,000 in this make and model · 8,800 as pilot in command · 25 in the last 90 days · 1 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
Calm
Visibility
1 statute miles
Lowest ceiling
200 ft
Temperature
57 °F, dew point 57 °F
Altimeter
29.00 inHg
Observed at
SBP

FAA reports on this event · 1

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