Pilot Debrief

CESSNA 340A near Orlando, FL — 2018-06-25

Final reportWPR18LA179
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Date
2018-06-25
Location
Orlando, FL, USA
Airport
ORL
Aircraft
CESSNA 340A
Registration
N60E
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Takeoff roll

Probable cause

The pilot's delayed decision to discontinue the takeoff when confronted with abnormal acceleration and airspeed indication; the reason for the abnormal acceleration could not be determined based on the available information.

NTSB narrative

The pilot reported that engine start, run-up, and taxi were all normal in preparation for the personal flight. The pilot began the takeoff roll using the full length of the dry, paved 6,000-ft runway, but shortly thereafter he felt a "sudden lag." The maximum speed he observed on the airspeed indicator was 43 knots, and the airspeed indicator needle "seemed to be fluttering." He confirmed that the engine controls were properly set and then decided to discontinue the takeoff about halfway down the runway by reducing power and applying the brakes and spoilers to decelerate the airplane. The airplane did not appear likely to stop before overrunning the end of the runway, so the pilot steered the airplane to the right as it ran off the runway end. The airplane impacted and stopped in a culvert about 500 ft beyond the runway and sustained substantial damage to the fuselage nose. Postaccident examination of the airplane, airspeed indication system, and engines did not reveal any preimpact mechanical malfunctions or failures that would have precluded normal operation. Several months after the accident, the airplane was repaired, and engine test runs revealed two minor but unrelated turbocharger problems. One problem affected the left engine, and the other affected the right engine, but they did not manifest themselves concurrently. In each case, the affected engine did not develop full rpm, but the other engine did develop full rpm. The investigation was unable to determine whether these problems existed at the time of the accident takeoff. If they did exist, unless they occurred simultaneously, they would have manifested as a significant asymmetric thrust between the two engines, which would have been obvious to the pilot. The pilot did not report any shortcomings in engine rpm or such thrust asymmetry. The airplane was subsequently ferried to its destination, and both engines operated normally for that flight. Accident site review revealed that the airplane traversed a total distance of about 6,500 ft during its takeoff roll and stop. Calculations performed postaccident indicate that, with a normal acceleration to 43 knots, had the airplane continued at that speed, it would have taken 35 seconds to reach the halfway point of the runway, at which point the pilot would have had 3,000 ft remaining to stop from 43 knots, which should have been sufficient. The investigation was unable to determine the reason for the airplane not accelerating above 43 knots. However, the pilot's delay in aborting the takeoff when the airplane did not accelerate above 43 knots resulted in the runway overrun.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have aborted takeoff earlier based on engine performance indications.

NTSB coding

Evidence available

  • 13 docket documents
View NTSB final reportView NTSB docket

Docket documents13

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