# NTSB MIA03LA163: Beech 400A, N51NP, St. Augustine, FL, August 18, 2003 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: August 18, 2003, 07:08 local (11:08 UTC) - Place: St. Augustine, FL - Coordinates: 29.959722, -81.340553 - Nearby events: https://openairdocs.org/map.md?lat=29.9597&lon=-81.3406&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report October 27, 2005 - Report: Approved by Office Director - Parties: Scott Aviation Division of Scott Technologies, Inc, Hydro-Aire, Inc., FAA, Engine & Propeller Directorate, Aircraft Braking Systems Corporation, FAA, Flight Standards District Office, Commercial Aircraft Products LLC, Executive Beechcraft inc., FAA Flight Standards District Office - NTSB case key (mKey): 57724 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA03LA163 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/57724/pdf - Page: https://openairdocs.org/ntsb/MIA03LA163 ## Probable cause The inadvertent left brake application by the copilot during the takeoff roll and the delay by the pilot-in-command to abort the takeoff resulting in a loss of directional control, and on-ground encounter with terrain. ## 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 - brakes(normal) - inadvertent, copilot/second pilot (cause) - aborted takeoff - delayed, pilot in command (cause) - directional control - not maintained - On ground/water encounter with terrain/water, takeoff - aborted - terrain condition - grass ## Analysis The copilot who had 60.4 hours total time in make and model, was seated in the left seat and was flying pilot for the part 91 positioning flight. An intersection departure was performed which provided 6,300 feet of usable runway for takeoff. The copilot was unsure how to release the parking brake before the flight was cleared for takeoff; the PIC had to instruct him how to do so. During the takeoff roll on runway 31 with a 4-knot wind from 240 degrees, the CVR recorded the PIC to state "V1", followed one second later by "rotate." Approximately 1 second later, the CVR recorded the copilot to state "whoa", followed by the cockpit area microphone recording an unidentified squealing sound. The PIC stated that the airplane turned abruptly 30 degrees to the left, and he initiated the aborted takeoff. He applied the brakes, reduced thrust, and applied both thrust reversers. In an attempt to maintain directional control, he and the copilot applied right rudder input and pumped the right brake, but the airplane departed the left side of the runway about 2,000 feet from the departure end of the runway. One of the main landing gears contacted an arresting cable, and the airplane continued onto grass. The anti-skid system tested OK before takeoff; and was on for takeoff. The PIC further stated the left main landing gear tire had good tread remaining prior to the flight. The left main landing gear tire was flat spotted. A 2,000 foot-long skid mark to the left of the runway centerline began approximately 1,850 feet from the point where the takeoff roll began. Examination of the left brake, both brake mixing valves, left and right wheelspeed transducers, power brake valve, control unit, and both parking brake valves revealed no evidence of preimpact failure or malfunction that would have resulted in left brake application. The company pilots are trained to utilize challenge/response to checklist items. Review of the CVR and the procedures listed in the airplane's "Before Starting Engines", "Starting Engines", "Before Taxi", "Taxi", and "Before Takeoff" checklists revealed none of the 5 checklists were verbally completed, and none of the checklists were completed at all with respect to challenge/response. Approximately 8 seconds elapsed from the time a squealing sound was heard on the CVR to the time when the copilot advised the PIC to "power off", which clarified his previous comment "hit it, hit it." ## Factual narrative HISTORY OF FLIGHT On August 18, 2003, about 0708 eastern daylight time, a Beech 400A, N51NP, registered to AC Expeditions, LLC, operated by Executive Beechcraft, Inc., experienced a loss of directional control on takeoff from St. Augustine Airport, St. Augustine, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 CFR Part 91 positioning flight from St. Augustine Airport, to Hickory Regional Airport, Hickory, North Carolina. The airplane was substantially damaged and the airline transport-rated pilot and copilot were not injured. The flight was originating at the time of the accident. The pilot-in-command (PIC) seated in the right front seat stated the copilot was flying the airplane, and the calculated V1 speed was 107 knots with 10 degrees of flaps selected. The airplane was stopped with the parking brake applied at the D1 intersection, and after being cleared for takeoff, the parking brake was released and a rolling takeoff from runway 31 was initiated. During the takeoff roll at 105 knots, the airplane turned abruptly 30 degrees to the left, and he initiated the aborted takeoff. He applied the brakes, reduced thrust, and applied both thrust reversers. In an attempt to maintain directional control he and the copilot applied right rudder input and pumped the right brake, but the airplane departed the left side of the runway about 2,000 feet from the departure end of the runway. One of the main landing gears contacted an arresting cable, and the airplane continued onto grass. He further stated that prior to reaching 105 knots, there was no abnormal engine indications. The anti-skid system tested OK before takeoff; anti-skid was selected "on" for the takeoff. He further stated the left main landing gear tire had good tread remaining prior to the flight. The copilot stated that he advanced the throttle to target 98.2 percent N1, and the non-flying pilot fine tuned them for the desired target N1 speed. Callouts for airspeed alive, and 80 knots crosscheck were made. At approximately 105 knots, the captain called V1, and at this point the aircraft "...severely yawed about 30 degrees to the left...." He applied full right rudder input, but the aircraft was unresponsive. The captain advised him to abort the takeoff, and he applied throttles to idle, reverse thrust, and speed brakes, and right brake to no avail. The aircraft continued veering to the left and at the point when the aircraft approached the side of the runway, he felt the main tire "...blow up, it was impossible to maintain any kind of directional control at this point, the aircraft then veered [off] the side of the runway and continued its path onto the grass...." They evacuated the aircraft, and the captain contacted their company. According to a transcription of communications with the St. Augustine Airport (KSGJ) Air Traffic Control Tower (ATCT), a flightcrew member received IFR clearance at 0702:06, and received taxi clearance at 0709:40; the flight was cleared to taxi to runway 31, hold short of the "D1" intersection. At 0714:19, a flightcrew member advised the local controller that the flight was ready to depart; takeoff clearance from the intersection of runway 31 and D1 was granted at 0714:21, which was acknowledged by a flightcrew member. The next communication was from the controller at 0715:50, in which the controller called out the airplane's registration. According to the cockpit voice recorder (CVR) transcript, the first 13 minutes 13 seconds of the approximately 30-minute recording contained nothing but sounds consistent with an aircraft sitting at the gate with ground power applied. At 0652:11, the St. Augustine Automated Weather Observing System (AWOS) was recorded indicating the wind was from 260 degrees at 5 knots, and altimeter setting was 30.04 inHg. At 0652:29, the copilot establish contact with ground control and requested IFR clearance to the destination airport. The ground controller provided the IFR clearance, which was readback by the copilot. At 0659:02, the CVR recorded the copilot to state "good to start one" followed by eight seconds later "we're, we're starting two." The PIC responded "kill the avionics." At 0700:15, the PIC's hot microphone recorded him to state "throttles." At 0700:53, the CVR recorded the PIC to state "you got the parking brake", to which the copilot stated "Yep." At 0701:03, the PIC stated "can you release the b uh?... there we go." At 0701:34, the CVR recorded the PIC to state "you already got the ATIS and everything?", to which the copilot stated "yeah, I got the clearance and everything..." At 0701:55, the PIC established contact with ground control and requested taxi clearance, which was provided by the ground controller. At 0702:54, the CVR recorded the PIC to state "brakes and antiskid", there was no response from the copilot. At 0703:07, the CVR recorded the copilot to state "my brakes are working. you wanna tap your brakes?" The PIC responded "yeah", followed by "this jeez, I can't even reach the damn pedals over here", to which the copilot responded "me neither." At 0703:14, the PIC reported "there we go.... you, your airplane." Between 0703:52, and 0705:13, the CVR recorded communications consistent with the flight crew members putting information into the flight management system (FMS). At 0705:22, the PIC stated "parking brake" to which the copilot responded "I can't pull the * You have to step on the brake or something, or is it stuck?" The PIC immediately responded "huh? no, p push down on it", to which the copilot responded "oh there you go." The local controller cleared the flight to take off at 0706:37, which was acknowledged by the PIC. At 0707:01, the PIC stated "one oh seven, one thirteen, and one twenty" referring to V1, Vr, and V2 speeds. The CVR transcript continues and at 0707:35, the CVR recorded the PIC to state "airspeed's alive on two tapes", followed by "we're in the green", then "80 knots, good to go." At 0707:47, the CVR recorded the PIC to state "V one", followed one second later by "rotate." At 0707:49, the CVR recorded the copilot to state "whoa." One second later the cockpit area microphone recorded an unidentified squealing sound, followed by a comment from the copilot three seconds later "hit it, hit it." The PIC questioned what the copilot was referring to, and the copilot responded at 0707:58, "power off." Approximately 3 seconds later the cockpit area microphone recorded a sound of rattling and bumping. The PIC then ordered evacuation of the aircraft, and at 0708:12, the cockpit area microphone recorded the sounds of decreasing engine rpm. PERSONNEL INFORMATION The pilot-in-command seated in the right front seat was the holder of an airline transport pilot certificate with airplane multi-engine land rating, and BE-400A type rating. He was issued a first class medical certificate on June 4, 2003, with no limitations. He reportedly had accumulated 60.4 hours total time in the accident make and model airplane. The copilot seated in the left front seat was the holder of an airline transport pilot certificate with airplane multi-engine land rating, and BE-400A type rating. He was issued a first class medical certificate on May 29, 2003, with no limitations. He also reportedly had accumulated 60.4 hours total time in the accident make and model airplane, with 5.0 hours as pilot-in-command. On June 20, 2003, both the captain and copilot satisfactorily completed Executive Beechcraft, Inc.'s BE400A and FAR Part 135 initial pilot training. The training occurred from June 9 to June 20, 2003, and included 64.5 hours of ground and 29.5 hours of simulator training conducted at FlightSafety International Raytheon Aircraft Learning Center in Wichita, Kansas. AIRCRAFT INFORMATION The airplane was manufactured by Raytheon Aircraft Company as a 400A, de ## Aircraft - Registration: N51NP (not matched to a registry record) - Reported make and model: Beech 400A - Category: Airplane - Serial number: RK-224 - Airframe hours: 1087.3 - Engines: Pratt & Whitney JT15D-5 2900 lbs thrust turbo fan - Damage: Substantial damage - Flight: Positioning, Part 91 - Operator: Executive Beechcraft, Inc. - Registered owner: AC Expeditions LLC - Airworthiness certificate: Standard, Transport - Last inspection: AAIP, January 16, 2003, 90.2 hours before - Departed: KSGJ, St. Augustine, FL - Destination: KHKY, Hickory, NC - Flight plan: IFR - Airport: KSGJ, St Augustine Airport, runway 31, 6,300 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; injuries: none; airline transport, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review June 1, 2003; seat: right; toxicology performed; flight hours: 9,343 total, 60 in this make and model, 8,182 as pilot in command - Co-pilot; age 29; injuries: none; commercial, flight instructor, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review June 1, 2003; seat: left; toxicology performed; flight hours: 3,100 total, 60 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 72 °F - Altimeter: 30.04 inHg - Observed at: KSGJ ## 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 20030818021129A](https://openairdocs.org/incident/20030818021129A), Aug 18, 2003: Beech 400A, St Augustine, FL, Minor damage. (-23) The PIC reported a loss of directional control at 105 knots just prior to V1 during takeoff roll. The takeoff was aborted and the aircraft veered left… 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.