WPR14CA387

NTSB accident investigation · Beech E33A · Las Vegas, NV · September 21, 2014

Accident · No injuriesData collectionFinal report
Date
September 21, 2014, 15:00 local (22:00 UTC)
Place
Las Vegas, NV
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Standing
Aircraft
N15RJBeech E33A
Defining event
Standing-engine(s) start-up: Ground collision
Weather
Visual (VMC) · Day
Status
Completed · report January 12, 2015
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
FAA
FAA report
20140921019829A
Case key
90153

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot's incorrect engine start procedures, which included improper throttle position and failure to keep the brakes applied, which resulted in a loss of directional control and subsequent collision with a parked airplane.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotBeech E33A: 1 caseAll aircraft: 1,391 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech E33A: 1 caseAll aircraft: 3,958 casesProbable cause
Object/animal/substance: aircraftEnvironmental issues › Physical environment · Not specifiedBeech E33A: 1 caseAll aircraft: 116 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The owner/pilot had recently purchased the high performance, complex airplane, and he wanted to have another pilot accompany him while he familiarized himself with the airplane's flight and operational characteristics. He contacted a flight instructor, who was referred to him by another individual, to fulfill that role. Based on discussions with the owner, and the owner's significant number of flight hours, the instructor planned to perform in the role of safety pilot, as opposed to providing instruction. The airplane was parked in a row of aircraft that was separated from another row of aircraft by a strip of pavement about 60 feet wide. The airplane pitch and roll flight controls were of the "throwover" design, where there was only one yoke, which could be shifted to either the left or right cockpit position. The right cockpit position was not equipped with brake pedals. The owner took the left seat, while the safety pilot took the right seat. The owner's preflight and pre-start procedures all seemed normal and uneventful, and did not give the safety pilot any reason to more closely observe or doubt the owner's abilities. According to the safety pilot, the engine started "very aggressively," increased to a high rpm, and the airplane immediately began moving rapidly forward out of its parking spot. Once the safety pilot realized that the airplane was accelerating towards the row of airplanes on the other side of the pavement, he moved his left foot over and tried to apply the brakes, in part by stepping on the owner's right foot. After the airplane had traveled about "10 to 15 feet," the safety pilot also fully retarded the mixture control to cut the engine. The airplane continued across the ramp, and struck a parked, unoccupied airplane. The parked airplane received substantial damage to its fuselage and wing structure. The left wing of the accident airplane was substantially damaged. The safety pilot recalled that prior to and during the engine start, the throttle control appeared to be in a sufficiently retarded position for engine start, but the owner reported that he had positioned the throttle control inappropriately for engine start. Postaccident examination of the throttle control system did not reveal any mechanical anomalies that would have precluded normal operation.

Factual narrative

The owner/pilot had recently purchased the high performance, complex airplane, and he wanted to have another pilot accompany him while he familiarized himself with the airplane's flight and operational characteristics. He contacted a flight instructor, who was referred to him by another individual, to fulfill that role. Based on discussions with the owner, and the owner's significant number of flight hours, the instructor planned to perform in the role of safety pilot, as opposed to providing instruction. The airplane was parked in a row of aircraft that was separated from another row of aircraft by a strip of pavement about 60 feet wide. The airplane pitch and roll flight controls were of the "throwover" design, where there was only one yoke, which could be shifted to either the left or right cockpit position. The right cockpit position was not equipped with brake pedals. The owner took the left seat, while the safety pilot took the right seat. The owner's preflight and pre-start procedures all seemed normal and uneventful, and did not give the safety pilot any reason to more closely observe or doubt the owner's abilities. According to the safety pilot, the engine started "very aggressively," increased to a high rpm, and the airplane immediately began moving rapidly forward out of its parking spot. Once the safety pilot realized that the airplane was accelerating towards the row of airplanes on the other side of the pavement, he moved his left foot over and tried to apply the brakes, in part by stepping on the owner's right foot. After the airplane had traveled about "10 to 15 feet," the safety pilot also fully retarded the mixture control to cut the engine. The airplane continued across the ramp, and struck a parked, unoccupied airplane. The parked airplane received substantial damage to its fuselage and wing structure. The left wing of the accident airplane was substantially damaged. The safety pilot recalled that prior to and during the engine start, the throttle control appeared to be in a sufficiently retarded position for engine start, but the owner reported that he had positioned the throttle control inappropriately for engine start. Postaccident examination of the throttle control system did not reveal any mechanical anomalies that would have precluded normal operation.

Aircraft

Registration
N15RJ
Reported as
Beech E33A
Category
Airplane
Serial number
CE-199
Built
1968
Airframe hours
3,690
Engine
Cont Motor IO 520 SERIES, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 1, 2014 · 20 hours before
Departed
KVGT · Las Vegas, NV
Destination
KVGT · Las Vegas, NV
Airport
KVGT · North Las Vegas

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
88
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
July 25, 2014
Seat
Left
Restraint
4-point
Flight hours
4,800 total · 4,000 in this make and model
Role
Other flight crew
Age
24
Injuries
None
Certificate
Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Unknown
Last flight review
March 25, 2014
Seat
Right
Flight hours
670 total · 0 in this make and model · 670 as pilot in command · 148 in the last 90 days · 30 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Lowest ceiling
None

Docket · 5

The files NTSB released with the investigation on December 30, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.7 MB in all.

FAA reports on this event · 1

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