Pilot Debrief

Beech 55 near San Antonio, TX — 2018-10-05

Final reportGAA19CA011
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Date
2018-10-05
Location
San Antonio, TX, USA
Airport
SAT
Aircraft
Beech 55
Registration
N6674Y
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Takeoff roll

Probable cause

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.

NTSB narrative

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

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot did not check pitch trim setting before takeoff.

NTSB coding

Evidence available

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

Docket documents4

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