WPR09LA451

The pilot's failure to maintain directional control after takeoff. Contributing to the accident was the pilot's inadequate preflight and failure to follow the airplane manufacturer's checklist to ensure that the rudder trim control and right propeller control lever were positioned correctly.

The airplane just had undergone a routine maintenance and this was planned to be the first flight after the inspection. During the initial climb, the pilot observed that the airplane was drifting to the left. The pilot attempted to counteract the drift by application of right aileron and right rudder, but the airplane continued to the left. The pilot reported that, despite having both hands on the control yoke, he could not maintain directional control and the airplane collided into a building. The airplane subsequently came to rest on railroad tracks adjacent to the airport perimeter. A post accident examination revealed that the elevator trim wheel was located in the 9-degree NOSE UP position; normal takeoff range setting is between 2 and 3 degrees NOSE UP. The rudder trim control knob was found in the full left position and the right propeller lever was found about one-half inch forward of the FEATHER position; these control inputs both resulted in the airplane yawing to the left. The pilot did not adequately follow the airplane manufacturer's checklist during the preflight, taxi, and before takeoff, which resulted in the airplane not being configured correctly for takeoff. This incorrect configuration led to the loss of directional control immediately after rotation. A post accident examination of the airframe, engines, and propellers revealed no anomalies that would have precluded normal operation.

HISTORY OF FLIGHT On September 16, 2009, about 1215 Pacific daylight time, a Raytheon Aircraft Company B200, N726CB, sustained substantial damage after impacting terrain while maneuvering during initial climb at the Hayward Executive Airport (HWD), Hayward, California. The commercial pilot, the sole occupant, was not injured. Visual meteorological conditions prevailed for the local flight, which was operated in accordance with 14 Code of Federal Regulations (CFR) Part 91, and no flight plan was filed. The flight was originating at the time of the accident, with its destination being the San Carlos Airport (SQL), San Carlos, California. In a report submitted to the Safety Board investigator-in-charge (IIC), the pilot reported that this was the first flight after maintenance had been performed on the airplane. The pilot stated that during the takeoff roll on runway 28R there were no warning lights when he started down the runway and that both engines were delivering full power. The pilot further stated, “…after the takeoff the airplane started drifting left. I applied right aileron and right rudder. I was still drifting left and had full right aileron. I landed at the edge of the airport.” In a personal interview conducted by a Federal Aviation Administration (FAA) aviation safety inspector, the pilot revealed that when he was 100 feet off the ground the airplane started to veer to the left, and that the airspeed was between 95 and 100 [knots]. The pilot stated that he then “kicked in ‘hard’ right rudder,” and at this point the engine power seemed normal. The pilot added that he had both hands on the yoke until the airplane crashed. The inspector reported that when asked about the use of the airplane’s checklist, the pilot stated, “Yes, but during taxi.” A FAA inspector who responded to and examined the accident site reported that the airplane initially struck an industrial building (off airport property) near the top of the structure with its left main landing gear [tire], and that the tire mark was between 20 feet to 30 feet in length. The inspector stated that wing parts were also located on top of the building. The inspector added that a second industrial building, which was located about 40 feet to 50 feet west of the first building, was also struck by the airplane. The inspector reported that it appeared that the aircraft was "riding" along the top edge of the building with the left engine striking the top side of the building. The right wing was low, and a collision occurred with the right main [landing] gear against a railroad car parked immediately beside the building. The inspector stated that this collision turned the aircraft 360 degrees, almost immediately causing the aircraft to slide off the end of the railroad car. The inspector added that the “tail-first flight” ended with the aircraft sliding backwards on [the] railroad tracks until it came to an abrupt stop. PERSONNEL INFORMATION A review of FAA records revealed the 37 year old pilot possessed a commercial pilot certificate for airplane land, instrument airplane, rotorcraft-helicopter, and a private pilot certificate for airplane single-engine land. The pilot’s most recent second-class FAA airman medical certificate was issued on October 22, 2009, without limitations. The pilot revealed that his most recent biennial flight review was conducted on February 24, 2009 in a King Air B200 airplane. The pilot reported a total flight time of 2,913 hours, of which 1,707 hours were in the same make and model as the accident airplane. AIRCRAFT INFORMATION The airplane was a 2001 Raytheon Aircraft Company B200, serial number BB-1750, which had accumulated a total engine and airframe time of 1,229.6 hours at the time of the accident. The airplane underwent its most recent Continuous Airworthiness inspection on September 10, 2009. The accident flight was the first flight subsequent to the completion of this inspection. In a telephone conversation with the IIC, the service manager of Mather Aviation, LLC, of Hayward, California, the firm that performed the most recent maintenance on the accident airplane, the maintenance work performed on the airplane was described as “routine maintenance.” The service manager added that the airplane was not brought into their facility because of “some other problem” that had just recently occurred. When asked by the IIC if he could recall anyone having repositioned any of the airplane’s trim controls while maintenance was being performed on the airplane, he replied that the trim controls were never touched by any of his maintenance personnel who worked on the airplane. The service manager stated that the trim controls were in the same position when the airplane was returned to the owner as they were when it was delivered to their facility for maintenance. As part of the most recent maintenance that was performed on the airplane, the service manager reported that a 1,200 hour throttle stop pin inspection (throttle catch gate) was performed. In a statement provided by Mather Aviation’s Director of Quality Assurance, the inspection was accomplished by an alternate means than is described in the Hawker Beechcraft Corporation Super King Air 200 Series Maintenance Manual, Chapter 76-00-00, page 211. The Director of Quality Assurance stated, “It is Mather Aviation policy to not disturb fight controls for access to areas to be inspected, unless no other means of access is available. In this case (power lever stop pin wear inspection) it is our practice to use a boroscope through the throttle lever arm cutouts on the pedestal. This affords a better view of the pin and provides a better view of the contact area to gauge the wear than by visual reference with the flashlight and mirror after opening the pedestal side panel and disturbing the trim wheel and rigging as is described in the maintenance manual.” According to the Hawker Beechcraft maintenance manual, the description for the inspection of the power lever detent pin is as follows: a. Disconnect all electrical power. b. Remove the pilot’s seat assembly from the airplane. c. Remove the screw and washer that secure both the elevator trim tab control wheel and the left end of the engine control lever pivot shaft to the left side of the pedestal. Index the position of the elevator trim tab control wheel for later installation. d. Remove the upholstery panel from the left side of the pedestal. e. Using a mirror and flashlight, inspect the upper power lever detent pin (Ref. Figure 206) on each power lever for excessive wear in the groove where the detent pin travels on the idle/reverse stop assembly between the levers. Wear of the pin’s diameter by a 1/3 or more is considered excessive. f. If excessive wear of the pin is indicated, the power lever assembly must be replaced as follows: METEOROLOGICAL INFORMATION At 1154, about 21 minutes prior to the accident, the HWD Automated Surface Observing System (ASOS), reported wind 290 degrees at 7 knots, visibility 10 miles, sky clear, temperature 21 degrees Celsius (C), dew point 14 degrees C, and an altimeter setting of 30.08 inches of Mercury. At 1236, about 21 minutes after the accident, the HWD ASOS issued a Special weather observation, which reported wind 290 degrees at 7 knots, visibility 4 miles in haze, few clouds at 900 feet, temperature 20 degrees C, dew point 14 degrees C, and an altimeter setting of 30.08 inches of Mercury. WRECKAGE AND IMPACT INFORMATION An on-scene inspection of the wreckage by FAA aviation safety inspectors revealed that the airplane came to rest on a set of industrial railroad tracks, with the airplane’s fuselage oriented on a 45-degree angle across the tracks and on a magnetic heading of about 150 degrees. The tail section of the airplane, which remained intact, came to rest up against the airport’s sound boundary fence, with