NTSB Factual Report

HISTORY OF FLIGHT

On August 18, 2003, about 0708 eastern daylight time, a Beech 400A, N51NP, registered to AC Expeditions, LLC, operated by Executive Beechcraft, Inc., experienced a loss of directional control on takeoff from St. Augustine Airport, St. Augustine, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 CFR Part 91 positioning flight from St. Augustine Airport, to Hickory Regional Airport, Hickory, North Carolina. The airplane was substantially damaged and the airline transport-rated pilot and copilot were not injured. The flight was originating at the time of the accident.

The pilot-in-command (PIC) seated in the right front seat stated the copilot was flying the airplane, and the calculated V1 speed was 107 knots with 10 degrees of flaps selected. The airplane was stopped with the parking brake applied at the D1 intersection, and after being cleared for takeoff, the parking brake was released and a rolling takeoff from runway 31 was initiated. During the takeoff roll at 105 knots, the airplane turned abruptly 30 degrees to the left, and he initiated the aborted takeoff. He applied the brakes, reduced thrust, and applied both thrust reversers. In an attempt to maintain directional control he and the copilot applied right rudder input and pumped the right brake, but the airplane departed the left side of the runway about 2,000 feet from the departure end of the runway. One of the main landing gears contacted an arresting cable, and the airplane continued onto grass. He further stated that prior to reaching 105 knots, there was no abnormal engine indications. The anti-skid system tested OK before takeoff; anti-skid was selected "on" for the takeoff. He further stated the left main landing gear tire had good tread remaining prior to the flight.

The copilot stated that he advanced the throttle to target 98.2 percent N1, and the non-flying pilot fine tuned them for the desired target N1 speed. Callouts for airspeed alive, and 80 knots crosscheck were made. At approximately 105 knots, the captain called V1, and at this point the aircraft "...severely yawed about 30 degrees to the left...." He applied full right rudder input, but the aircraft was unresponsive. The captain advised him to abort the takeoff, and he applied throttles to idle, reverse thrust, and speed brakes, and right brake to no avail. The aircraft continued veering to the left and at the point when the aircraft approached the side of the runway, he felt the main tire "...blow up, it was impossible to maintain any kind of directional control at this point, the aircraft then veered [off] the side of the runway and continued its path onto the grass...." They evacuated the aircraft, and the captain contacted their company.

According to a transcription of communications with the St. Augustine Airport (KSGJ) Air Traffic Control Tower (ATCT), a flightcrew member received IFR clearance at 0702:06, and received taxi clearance at 0709:40; the flight was cleared to taxi to runway 31, hold short of the "D1" intersection. At 0714:19, a flightcrew member advised the local controller that the flight was ready to depart; takeoff clearance from the intersection of runway 31 and D1 was granted at 0714:21, which was acknowledged by a flightcrew member. The next communication was from the controller at 0715:50, in which the controller called out the airplane's registration.

According to the cockpit voice recorder (CVR) transcript, the first 13 minutes 13 seconds of the approximately 30-minute recording contained nothing but sounds consistent with an aircraft sitting at the gate with ground power applied. At 0652:11, the St. Augustine Automated Weather Observing System (AWOS) was recorded indicating the wind was from 260 degrees at 5 knots, and altimeter setting was 30.04 inHg. At 0652:29, the copilot establish contact with ground control and requested IFR clearance to the destination airport. The ground controller provided the IFR clearance, which was readback by the copilot. At 0659:02, the CVR recorded the copilot to state "good to start one" followed by eight seconds later "we're, we're starting two." The PIC responded "kill the avionics." At 0700:15, the PIC's hot microphone recorded him to state "throttles." At 0700:53, the CVR recorded the PIC to state "you got the parking brake", to which the copilot stated "Yep." At 0701:03, the PIC stated "can you release the b uh?... there we go." At 0701:34, the CVR recorded the PIC to state "you already got the ATIS and everything?", to which the copilot stated "yeah, I got the clearance and everything..." At 0701:55, the PIC established contact with ground control and requested taxi clearance, which was provided by the ground controller. At 0702:54, the CVR recorded the PIC to state "brakes and antiskid", there was no response from the copilot. At 0703:07, the CVR recorded the copilot to state "my brakes are working. you wanna tap your brakes?" The PIC responded "yeah", followed by "this jeez, I can't even reach the damn pedals over here", to which the copilot responded "me neither." At 0703:14, the PIC reported "there we go.... you, your airplane." Between 0703:52, and 0705:13, the CVR recorded communications consistent with the flight crew members putting information into the flight management system (FMS). At 0705:22, the PIC stated "parking brake" to which the copilot responded "I can't pull the * You have to step on the brake or something, or is it stuck?" The PIC immediately responded "huh? no, p push down on it", to which the copilot responded "oh there you go." The local controller cleared the flight to take off at 0706:37, which was acknowledged by the PIC. At 0707:01, the PIC stated "one oh seven, one thirteen, and one twenty" referring to V1, Vr, and V2 speeds. The CVR transcript continues and at 0707:35, the CVR recorded the PIC to state "airspeed's alive on two tapes", followed by "we're in the green", then "80 knots, good to go." At 0707:47, the CVR recorded the PIC to state "V one", followed one second later by "rotate." At 0707:49, the CVR recorded the copilot to state "whoa." One second later the cockpit area microphone recorded an unidentified squealing sound, followed by a comment from the copilot three seconds later "hit it, hit it." The PIC questioned what the copilot was referring to, and the copilot responded at 0707:58, "power off." Approximately 3 seconds later the cockpit area microphone recorded a sound of rattling and bumping. The PIC then ordered evacuation of the aircraft, and at 0708:12, the cockpit area microphone recorded the sounds of decreasing engine rpm.

PERSONNEL INFORMATION

The pilot-in-command seated in the right front seat was the holder of an airline transport pilot certificate with airplane multi-engine land rating, and BE-400A type rating. He was issued a first class medical certificate on June 4, 2003, with no limitations. He reportedly had accumulated 60.4 hours total time in the accident make and model airplane.

The copilot seated in the left front seat was the holder of an airline transport pilot certificate with airplane multi-engine land rating, and BE-400A type rating. He was issued a first class medical certificate on May 29, 2003, with no limitations. He also reportedly had accumulated 60.4 hours total time in the accident make and model airplane, with 5.0 hours as pilot-in-command.

On June 20, 2003, both the captain and copilot satisfactorily completed Executive Beechcraft, Inc.'s BE400A and FAR Part 135 initial pilot training. The training occurred from June 9 to June 20, 2003, and included 64.5 hours of ground and 29.5 hours of simulator training conducted at FlightSafety International Raytheon Aircraft Learning Center in Wichita, Kansas.

AIRCRAFT INFORMATION

The airplane was manufactured by Raytheon Aircraft Company as a 400A, designated serial number RK-224, and certificated in the transport category.

Review of the airplane maintenance records revealed the airplane was last inspected in accordance with an FAA Approved Aircraft Inspection Program (AAIP) "A,B Check" on January 16, 2003, at an airplane total time of 997.1 hours. The airplane had accumulated approximately 90 hours since the inspection. The maintenance records further indicate that on January 22, 2003, at an aircraft total time of approximately 1,003 hours, the "power brake valve" was removed, and an overhauled unit was installed. The aircraft had accumulated approximately 84 hours since the overhauled "power brake valve" was installed.

METEOROLOGICAL INFORMATION

A METAR weather observation taken at St. Augustine Airport at 0715, or at the approximate time of the accident, indicates the wind was from 240 degrees at 4 knots, the visibility was 10 statute miles, clear skies existed, the temperature and dew point were 23 and 22 degrees Celsius, respectively, and the altimeter setting was 30.05 inHg.

COMMUNICATIONS

The flightcrew was in contact with the St. Augustine Air Traffic Control Tower, there were no reported communication difficulties.

AIRPORT INFORMATION

The St. Augustine Airport is equipped in part with one runway designated 13/31, which is 7,996 feet long and 150 feet wide. At the time of the accident, a disabled airplane was located east of the displaced threshold for runway 31; therefore, 6,300 feet of runway was available for takeoff.

FLIGHT RECORDERS

The airplane was not equipped with a flight data recorder.

The airplane was equipped with a Fairchild A100S cockpit voice recorder (CVR). Readout of the CVR was performed by the NTSB Vehicle Recorders Division, located in Washington, D.C. Laboratory personnel determined that the recorder had been manually bulk-erased after the accident; however, the erased data was recovered using laboratory techniques. The CVR recorded communications from before starting the engines, to the comment from an unidentified occupant advising "get out, get out."

WRECKAGE AND IMPACT INFORMATION

Examination of the airplane and accident site was performed by the Federal Aviation Administration (FAA) inspector-in-charge, along with a representative of the airplane operator. Examination of the runway revealed a black mark on the runway surface associated with the left main landing gear tire first beginning about 3,500 feet down from the approach end of the runway, which was approximately 1,850 feet from the point where the airplane began the takeoff roll. The mark was just left of the centerline and continues down the runway approximately 2,000 feet, arching to the left. Black marks on the runway surface associated with the right and nose landing gear tires were noted beginning about 100 feet from the point where the airplane departed the runway. The airplane came to rest on grass south of the edge of the runway about 1,913 feet before the departure end of the runway. Review of pictures provided by Raytheon Aircraft Company personnel revealed the left main landing gear tire was deflated but still remained in position on the wheel; the tire was noted to be flat spotted.

Examination of the airplane revealed damage to the left wheel with no evidence of FOD inside the wheel and brake assembly. No loose or missing nuts or bolts were found on the brake to strut torque plate attachment. The pre-charge reading of the power brake valve accumulator was at a "normal" reading, and was also at a "normal" reading when the hydraulic system was pressurized. Additionally, the emergency air bottle pressure was at "normal" pressure reading. The brake and main system hydraulic reservoirs were at normal levels. Operational testing of the normal brake system and anti-skid systems revealed no evidence of failure or malfunction. A sample of fluid from the left brake was obtained which revealed no visual evidence of contamination.

Following the examination of the airplane, the left brake assembly, power brake control valve, anti-skid control valves, parking brake valves, and brake mixing valves were retained for further examination.

MEDICAL AND PATHOLOGICAL INFORMATION

Following the accident, the pilot and copilot submitted specimens for drug testing, the results for both was negative.

TESTS AND RESEARCH

Examination of the mixing valves was performed at the manufacturer's facility with FAA oversight. The safety wire had been removed from the bleeder valve of the left valve, while the safety wire on the bleeder valve of the right valve did not look like Commercial Aircraft Products winding method. No leakage was noted during the functional test of either the left or right valve during two high pressure tests; however, upon release of the pressure, both pistons appeared to stick and would not return to the released position smoothly. The remainder of the tests on both could not be performed due to the piston position. During disassembly of the left valve, an indistinguishable odor and contamination in the fluid were noted. There appeared to be an o-ring breakdown and metal flakes were observed. Scoring and scratches were observed in the bore of the cylinder and the o-ring showed slight wear. Upon removal of the o-ring and backup o-rings, the piston slid easily in the bore. The cylinder bore and piston dimensional measurements were within specifications. There were no other abnormalities observed. During disassembly of the right valve, no odor was noted, and slight contamination of the fluid was observed. Examination of the cylinder bore revealed full travel scoring. The o-ring had nicks and scratches to the sealing surface and there was some contamination between the backup o-ring and the o-ring. Some scratches were observed on the piston and with the o-ring and backup o-ring removed, the piston traveled in the cylinder bore with a slight tightness at mid travel. After the unit had been reassembled and wiped down, further functional testing was attempted but discontinued when the piston stuck at the same point. The cylinder bore dimensional measurement was within specifications, but the piston diameter was .0005 inch less than the minimum specified diameter. No other abnormalities were observed.

Examination of the power brake valve, control unit, and wheelspeed transducers was performed at the manufacturer's facility with FAA oversight. The functional testing of the control unit and both wheelspeed transducers revealed no abnormalities. An out of tolerance condition was found on the power brake valve; however, this abnormality would not affect the braking or antiskid performance of the aircraft.

Examination of the parking brake valves was conducted at the manufacturer's facility with FAA oversight. Functional and operational testing of both valves revealed both were operational, but both valves had serious leakage. Disassembly of both valves revealed the source of the leakage resulted from worn elastomeric material on the stem assembly. No other abnormal condition was observed in any other components of the left or right parking brake assemblies.

Examination of the left brake assembly was conducted at the manufacturer's facility with FAA oversight. The brake assembly was tested in accordance with the Component Maintenance Manual (CMM). The initial inspection revealed that the bolts holding the housing to the torque tube were loose. A large gouge and scraping damage were noted on areas of the housing. All stationary disks were determined to be less than 0.010 inch out-of-flat; the CMM limits for out-of-flat is 0.010 inch. Testing of rotor flatness could not be determined. During testing of the left brake from 15 to 950 psi, all pistons extended and retracted normally. No hydraulic fluid leakage was observed during the leak test. The clearance under two of the five pistons was less than specified. The shuttle valve passed CMM test requirements.

The director of flight operations for the operator reported their company pilots are trained to utilize challenge/response to checklist items. Review of the CVR transcript and the procedures listed in the airplane's "Before Starting Engines", "Starting Engines", "Before Taxi", "Taxi", and "Before Takeoff" checklists revealed none o

NTSB Probable Cause

The inadvertent left brake application by the copilot during the takeoff roll and the delay by the pilot-in-command to abort the takeoff resulting in a loss of directional control, and on-ground encounter with terrain.