# NTSB WPR15LA132: Beech B23, N7628R, Flagstaff, AZ, March 22, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: March 22, 2015, 11:15 local (18:15 UTC) - Place: Flagstaff, AZ - Coordinates: 35.140277, -111.669166 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.1403&lon=-111.6692&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report January 25, 2018 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 90907 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR15LA132 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90907/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90907 - Page: https://openairdocs.org/ntsb/WPR15LA132 ## Probable cause The pilot's failure to maintain directional control during landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [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 B23, 2 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=1151240), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech B23, 3 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1151240), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Object/animal/substance: runway/taxi/approach light](https://openairdocs.org/ntsb-findings/03022012): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Beech B23, 1 case](https://openairdocs.org/ntsb-findings/03022012/cases.md?model=1151240), [All aircraft, 106 cases](https://openairdocs.org/ntsb-findings/03022012/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Beech B23, 2 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=1151240), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490); cases with it: [Beech B23, 2 cases](https://openairdocs.org/ntsb-events/490/sequence.md?model=1151240), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) ## Analysis The private pilot reported that, during the takeoff roll for the local personal flight, the nosewheel seemed to turn slightly to the left. Rudder input maintained a straight path on the runway centerline, but the nosewheel side-skidded for a few seconds before the airplane lifted off. When the airplane returned for landing, the pilot stated that touchdown was smooth and uneventful. During the landing roll, the nosewheel turned slightly left, and he attempted to correct with full right rudder. The airplane continued to veer to the left, exited the runway, and impacted a precision approach path indicator (PAPI) light. The pilot stated that he felt that the right rudder bungee did not have enough pull to stop the nosewheel from continuing to turn more sharply to the left. However, a postaccident examination of the airplane and nosewheel steering mechanism did not reveal any mechanical anomalies that would have precluded normal operation. Thus, it is likely that the pilot failed to maintain directional control of the airplane during landing. ## Factual narrative On March 22, 2015, about 1115 mountain standard time, a Beech B23, N7628R, veered off runway 21 during the landing rollout at the Flagstaff Pulliam Airport (FLG), Flagstaff, Arizona. The private pilot/owner operated the airplane under the provisions of 14 Code of Federal Regulations Part 91 as a local area personal flight. The pilot and passenger were not injured. The airplane sustained substantial damage. Visual meteorological conditions prevailed for the local area flight, and no flight plan had been filed. The flight departed FLG about 1050. According to the pilot, just prior to rotation for takeoff, the nose wheel seemed to turn left slightly, rudder input maintained a straight path on the runway centerline, but the nose wheel side skidded for a few seconds before he rotated. They flew for about an hour and then returned to the airport for a full stop landing. The pilot stated that touchdown was smooth and uneventful. During the landing rollout, the nose wheel turned slightly left, and he corrected for the condition with full right rudder. He felt that the right rudder bungee did not have enough pull to stop the nose wheel from continuing to turn more sharply to the left. The pilot applied right brake, but was not able to correct the turn to the left. The airplane tipped up on its nose wheel and right main landing gear, which caused the nose wheel to turn more to the left. The pilot applied full power and elevator to reduce the weight off the nose wheel in an attempt to turn it to the right. The right wing struck a precision approach path indicator (PAPI) box, and the pivot tube on the left wing caught the top of another PAPI box. After coming to a stop, the pilot and passenger exited the airplane. Flagstaff airport reported wind from 230 degrees at 13 knots gusting to 20 knots. The airplane was inspected by a Federal Aviation Administration (FAA) inspector, with no mechanical anomalies identified. ## Aircraft - Registration: [N7628R](https://openairdocs.org/aircraft/N7628R), registered now, S/N M-1249, built 1969 (OpenAirDocs) - Reported make and model: BEECH B23 - Registry model: [Beech B23](https://openairdocs.org/model/beech-b23) (registry code 1151240) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: M-1249 - Year built: 1969 - Airframe hours: 5370.65 - Engines: LYCOMING O-360-A4G 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Aerobatic; Standard, Normal - Last inspection: Annual, July 1, 2014, 27 hours before - Departed: FLG, Flagstaff, AZ - Destination: FLG, Flagstaff, AZ - Airport: FLG, Flagstaff Pulliam, runway 21, 8,800 × 150 ft, asphalt - Equipment: Handheld GPS, Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: none; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; flight hours: 122 total, 21 in this make and model, 82 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 13 knots, gusting 20 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 55 °F, dew point 19 °F - Altimeter: 30.29 inHg - Observed at: FLG ## 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 20150322005209A](https://openairdocs.org/incident/20150322005209A), Mar 22, 2015: Beech B23, Flagstaff, AZ, Substantial damage. Aircraft cleared to land on runway 21. Winds at 230 at 13 gust 20. During roll out after landing aircraft commenced drifting to the left of centerline. Pilot… ## Docket (2 files) The files NTSB released with the investigation on October 30, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90907. 2.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457426&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation (NTSB) (item 2, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457428&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(NTSB)-Master.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.