# NTSB WPR14CA387: Beech E33A, N15RJ, Las Vegas, NV, September 21, 2014 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: September 21, 2014, 15:00 local (22:00 UTC) - Place: Las Vegas, NV - Coordinates: 36.210556, -115.194442 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.2106&lon=-115.1944&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing-engine(s) start-up: Ground collision](https://openairdocs.org/ntsb-events/200) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report January 12, 2015 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA - NTSB case key (mKey): 90153 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR14CA387 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90153/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90153 - Page: https://openairdocs.org/ntsb/WPR14CA387 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech E33A, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1151424), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech E33A, 1 case](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=1151424), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Object/animal/substance: aircraft](https://openairdocs.org/ntsb-findings/03022040): Environmental issues › Physical environment · Not specified; cases with it: [Beech E33A, 1 case](https://openairdocs.org/ntsb-findings/03022040/cases.md?model=1151424), [All aircraft, 116 cases](https://openairdocs.org/ntsb-findings/03022040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Standing-engine(s) start-up: Ground collision](https://openairdocs.org/ntsb-events/200) (defining event); cases with it: [Beech E33A, 1 case](https://openairdocs.org/ntsb-events/200/sequence.md?model=1151424), [All aircraft, 618 cases](https://openairdocs.org/ntsb-events/200/sequence.md) - [Standing-engine(s) start-up: Airport occurrence](https://openairdocs.org/ntsb-events/070); cases with it: [Beech E33A, 1 case](https://openairdocs.org/ntsb-events/070/sequence.md?model=1151424), [All aircraft, 56 cases](https://openairdocs.org/ntsb-events/070/sequence.md) - [Standing-engine(s) operating: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Beech E33A, 1 case](https://openairdocs.org/ntsb-events/060/sequence.md?model=1151424), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Standing-engine(s) operating: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Beech E33A, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=1151424), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) ## 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](https://openairdocs.org/aircraft/N15RJ), registered now, S/N CE-199, built 1968 (OpenAirDocs) - Reported make and model: BEECH E33A - Registry model: [Beech E33A](https://openairdocs.org/model/beech-e33a) (registry code 1151424) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: CE-199 - Year built: 1968 - Airframe hours: 3690 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 88; injuries: none; 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 - Other flight crew; age 24; injuries: none; 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 ## 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 20140921019829A](https://openairdocs.org/incident/20140921019829A), Sep 21, 2014: Beech E33A, N. Las Vegas, NV, Substantial damage. Aircraft collided with parked aircraft in shade hangars at North Las Vegas Airport. Pilot stated that when starting aircraft he had throttle "open" too FAR and… ## Docket (5 files) The files NTSB released with the investigation on December 30, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90153. 2.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1, Owner (item 1, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420430&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1,%20Owner-Redacted.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1, Safety Pilot (item 2, .PDF, 188 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420431&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1,%20Safety%20Pilot-Redacted.PDF - Record of Conversation – Safety Pilot (item 3, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420432&FileExtension=.PDF&FileName=Record%20of%20Conversation%20%E2%80%93%20Safety%20Pilot-Master.PDF - FAA Event Information (item 4, .PDF, 294 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420433&FileExtension=.PDF&FileName=FAA%20Event%20Information-Redacted.PDF - FAA Inspector Emails (item 5, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420434&FileExtension=.PDF&FileName=FAA%20Inspector%20Emails-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.