Pilot Debrief

BEECH A200 near Bridgewater, VA — 2008-09-25

Final reportNYC08LA323
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Date
2008-09-25
Location
Bridgewater, VA, USA
Airport
VBW
Aircraft
BEECH A200
Registration
N30W
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Landing

Probable cause

The pilot's decision to land with a tailwind on a short, wet runway, resulting in landing long and runway overrun. Contributing to the accident was the operator’s lack of standard operating procedures for test flights.

Contributing factors

Contributing to the accident was the operator’s lack of standard operating procedures for test flights.

NTSB narrative

The pilot, an employee of the United States Department of Interior (DOI), was conducting a post-maintenance test flight of the airplane, which was on long term lease to the DOI. For the flight, despite the presence of drizzle, a tailwind, and obstacles, the pilot elected to use a down-sloping, non-grooved runway with a 41:1 approach slope and a displaced threshold, with an available landing length of 2,377 feet. The pilot executed a go-around after touchdown on his first landing attempt, stating that something did not feel right with the landing. The pilot then attempted another landing, touching down approximately 700 feet down the runway before applying reverse thrust and brakes. Because the runway was wet, the braking action was poor and he realized that he was probably going to overrun the end of the runway. However, he elected not to go around due to the airplane’s low indicated airspeed, the configuration of the airplane, the remaining runway, the rising terrain, and the presence of houses. The airplane then rolled off the pavement on to grass, where the braking effectiveness was further reduced, before rolling down a steep embankment and into a river. The airplane sustained substantial damage to its wing structure during the accident sequence. Postaccident examination of the airplane revealed no preimpact mechanical malfunctions or abnormalities. Review of the DOI's National Business Center, Aviation Management Directorate's Operational Policy Memorandums (OPMs) did not reveal any guidance that pertained to test flights. Additionally, the "Aviation Management – Document Library Index"—which included the OPMs, information bulletins, handbooks, and reference guides—included no single operations manual containing all of the information for ready reference by the DOI's pilots, nor was a mandate discovered which would require them to have such information in their possession during flight operations.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Pilot should have aborted landing when feeling something was not right.

NTSB coding

Evidence available

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

Docket documents7

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