Wednesday, October 10, 2018

Abrupt Maneuver: Beech E-55 Baron, N6674Y, accident occurred October 05, 2018 at San Antonio International Airport (KSAT), Texas

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; San Antonio, Texas

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms


Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf


https://registry.faa.gov/N6674Y

Location: San Antonio, TX
Accident Number: GAA19CA011
Date & Time: 10/05/2018, 1130 CDT
Registration: N6674Y
Aircraft: Beech 55
Aircraft Damage: Substantial
Defining Event: Abrupt maneuver
Injuries: 1 Minor
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis 

The pilot reported that, the day before the accident flight, he had flown the airplane and wanted to become more comfortable with new instruments that had been installed. So, after the flight, while in a hangar, he and a friend turned the airplane's electrical power on to familiarize the pilot with the autopilot system and specifically with how it would follow heading bug settings. During the familiarization, they "ran the [pitch] trim all the way up."

The pilot added that, before takeoff for the accident flight, he did not check the pitch trim setting because he believed it would be the same as his previous flight, instead of the pitch trim setting after his autopilot ground familiarization. He added that, during takeoff, the nose pitched up severely. He lowered the nose, and the airplane entered a negative G condition. He realized that he "did not latch the seat belt very good" and saw that his seatbelt had disconnected and that he was no longer in his seat and could not regain airplane control. The airplane struck the runway, porpoised, and the nose landing gear collapsed. The airplane skidded and struck a taxiway light.

Postaccident examination of the airplane revealed that the vertical trim tab was in the full-down position, indicating that full nose-up trim was applied.

The airplane sustained substantial damage to both engines and the fuselage.

The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.

The Pilot's Operating Handbook checklist titled, "Before Takeoff," stated:

Seat Belts and Shoulder Harnesses – CHECK… 15. Trim – AS REQUIRED FOR TAKE-OFF 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's improper takeoff trim setting and failure to properly secure his seatbelt, which resulted in a loss of airplane control. Contributing to the accident was the pilot's failure to follow the Before Takeoff checklist.

Findings

Aircraft
Elevator tab control system - Incorrect use/operation (Cause)
Flight compartment equipment - Incorrect use/operation (Cause)
Pitch control - Attain/maintain not possible (Cause)

Personnel issues
Aircraft control - Pilot (Cause)
Task monitoring/vigilance - Pilot (Cause)
Use of checklist - Pilot (Factor)

Environmental issues
Runway/taxi/approach light - Contributed to outcome

Factual Information

History of Flight

Prior to flight
Miscellaneous/other

Takeoff
Abrupt maneuver (Defining event)
Abnormal runway contact
Landing gear collapse
Collision with terr/obj (non-CFIT)

Pilot Information

Certificate: Private
Age: 79, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Lap Only
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 06/21/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 09/20/2015
Flight Time:  (Estimated) 3907 hours (Total, all aircraft), 1322 hours (Total, this make and model), 3897 hours (Pilot In Command, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Beech
Registration: N6674Y
Model/Series: 55 E55
Aircraft Category: Airplane
Year of Manufacture: 1979
Amateur Built:No 
Airworthiness Certificate: Normal
Serial Number: TE-1168
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 03/20/2017, Annual
Certified Max Gross Wt.: 5324 lbs
Time Since Last Inspection:
Engines: 2 Reciprocating
Airframe Total Time: 5414.5 Hours at time of accident
Engine Manufacturer: Continental
ELT: C91  installed, not activated
Engine Model/Series: IO-520-CB8B
Registered Owner: Arx Inc
Rated Power: 285 hp
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KSAT, 789 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1651 UTC
Direction from Accident Site: 328°
Lowest Cloud Condition: Scattered / 2800 ft agl
Visibility:  10 Miles
Lowest Ceiling:
Visibility (RVR):
Wind Speed/Gusts: 9 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 140°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30 inches Hg
Temperature/Dew Point: 29°C / 21°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: San Antonio, TX (SAT)
Type of Flight Plan Filed: None
Destination: San Antonio, TX (SAT)
Type of Clearance: VFR
Departure Time: 1130 CDT
Type of Airspace: Class C 

Airport Information

Airport: SAN ANTONIO INTL (SAT)
Runway Surface Type: Concrete
Airport Elevation: 809 ft
Runway Surface Condition: Dry
Runway Used: 13R
IFR Approach: None
Runway Length/Width: 8502 ft / 150 ft
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Minor
Latitude, Longitude: 29.538889, -98.480278 (est)

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