Pilot Debrief

CESSNA 441 near Baltimore, MD — 2008-08-20

Final reportNYC08LA291
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Date
2008-08-20
Location
Baltimore, MD, USA
Airport
BWI
Aircraft
CESSNA 441
Registration
N441VB
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Takeoff roll

Probable cause

The pilot's delayed decision to abort the takeoff. Contributing to the accident was the pilot's attempted takeoff with a propeller start lock inadvertently engaged.

Contributing factors

Contributing to the accident was the pilot's attempted takeoff with a propeller start lock inadvertently engaged.

NTSB narrative

According to the pilot, the previous flight, as well as the accident event preflight procedures, start-up, and taxi were all normal. However, as the airplane accelerated during the takeoff roll, it moved "slightly to the left" on the runway. The pilot "added power on the left engine," but the airplane continued to the left, and the left wheel departed the left edge of the runway pavement. The pilot then aborted the takeoff, and continued efforts to correct the direction of travel by manipulating the engine power levers. The airplane veered further left, completely departed the paved surface, and struck an earthen mound about 200 feet to the left of the runway’s edge and 2,500 feet from the airplane’s starting point on the 5,000-foot runway. At the time, visual meteorological conditions prevailed with winds variable at 3 knots. The propellers were equipped with start locks which were required by checklists to be disengaged for taxi and flight. Although there were no discrete annunciators to advise start lock status, the airplane information manual provided means to recognize and correct when the start locks were not disengaged. Postaccident examination of the propeller assemblies revealed that the right propeller was properly configured for flight. However, the left propeller start lock mechanism was engaged, which resulted in negative propeller blade angles at the outboard stations and asymmetric thrust during the takeoff roll.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot did not verify propeller start locks were disengaged before takeoff.

NTSB coding

Evidence available

  • Photos
  • 7 docket documents
View NTSB final reportView NTSB docket

Docket documents7

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