History of Flight
On September 25, 2008, about 1715 eastern daylight time, a Beech A200, registration N30W, sustained substantial damage during a runway overrun while landing at Bridgewater Air Park (VBW), Bridgewater, Virginia. The certificated airline transport pilot and his one passenger were uninjured. Day visual meteorological conditions prevailed for the local maintenance flight. No flight plan was filed for the flight conducted under Title 14 Code of Federal Regulations Part 91.
The pilot, an employee of the United States Department of Interior (DOI), Bureau of Land Management, and a mechanic needed to perform a maintenance test flight to check the pressurization system before departing for California the following day. The pilot had followed the maintenance performed on the airplane during the day while attending other business associated with an avionics system upgrade. He requested replacement of the two right main tires and monitored that activity. At approximately 1700, the pilot had the airplane's main fuel tanks filled, performed his normal checks and walk-around, and taxied to the end of runway 33 for a pattern flight.
During a run-up to check pressurization, the pilot found it difficult to hold the airplane stationary with the brakes, which he considered common after tire servicing due to possible grease on discs and pads. His normal procedure was to taxi to the other end of the runway with light brake pressure to remove debris, and he usually departed runway 15 for better departure performance. On this occasion, he elected to use runway 33 despite a slight tailwind and did not take his usual action to ensure good braking. After departure, he performed checks on pressurization and flow packs, then set up for landing on runway 33. Upon touchdown, he decided to add power and go-around as something did not feel right, but he did not climb out to evaluate. He then came around for a second landing, touched down approximately 700 feet down the runway, set beta (reverse), and began braking. He realized he might overshoot due to poor braking action on the wet runway. The left brake skidded easily, and the right brake had poor braking until farther down the runway. He suppressed the urge to abort and go-around because of the airplane's low indicated airspeed, configuration, runway remaining, rising terrain, and houses. He attempted to turn left without side-loading the landing gear and thought he had stopped, but the airplane rolled off the pavement onto wet grass, where he had no braking. It then rolled down a steep embankment and entered the river at a 45-degree angle. The right wingtip hit first, then both propellers struck the riverbank edge and stopped immediately.
Aircraft and Personnel Information
The pilot's lower right leg had been surgically amputated in 1987. He was administered a combination Pilot Certification Test and Special Medical Flight Test in a Cessna 310 on February 6, 1990, and was issued a Statement of Demonstrated Ability. He did not fly with a prosthetic device. He held an airline transport pilot certificate with multiple ratings, including airplane multi-engine land, and reported 12,000 total flight hours, with 8,500 hours in multi-engine airplanes and 5,500 hours in the accident airplane make and model. His most recent FAA second-class medical certificate was issued on January 31, 2008.
The airplane was manufactured in 1977 and its most recent approved inspection was completed on August 7, 2008. At the time of the accident, it had accrued 16,447.7 total hours. The airplane was leased to the DOI on October 30, 2003, by Dynamic Aviation Group Incorporated and had been operated by the DOI since the signing of a long-term use contract. Prior to the test flight, two right main tires had been replaced, the pressurization controller tubing to the outflow valve, the drain valve for the pressurization controller line, and the outflow and safety valve tubing had been replaced, and a clamp on the left wing heat exchanger had been tightened. However, no documentation of this work had been entered into the airplane records, and FAA inspectors did not find a record of how the airplane was returned to service.
Meteorological and Airport Information
The reported weather at Shenandoah Regional Airport (SHD), Staunton, Virginia, located 7 nautical miles southeast of the accident site at 1700, included wind 070 degrees at 5 knots, visibility 10 miles, drizzle, fog, overcast at 2,300 feet, temperature 14 degrees Celsius, dew point 12 degrees Celsius, and an altimeter setting of 30.23 inches of mercury.
Bridgewater Air Park was a non-towered, public use airport. Runway 33 was 2,745 feet long by 60 feet wide, asphalt in good condition but not grooved. Skid marks matching the accident airplane's landing gear geometry began approximately 2,059 feet northwest of the displaced threshold and continued until they left the paved portion, where ground scars continued to the riverbank. Obstructions included a 35-foot pole displacing the threshold by 368 feet, located 1,277 feet from the approach end and 184 feet right of centerline. A 41:1 approach slope to the displaced threshold was published, with an available landing length of 2,377 feet. The runway sloped downward 0.3%.
Wreckage and Impact Information
Postaccident examination by an FAA inspector revealed substantial damage to the airplane's wing structure. No preimpact mechanical malfunctions or abnormalities of the braking system, flight controls, propeller controls, or engines were discovered.
Operational Control Issues
In a post-accident interview, the pilot stated the airplane was in public use. However, the DOI's National Business Center, Aviation Management Directorate's Aviation Safety Manager advised the NTSB that the airplane was not in public use and was on a maintenance test flight. Review of the contract between the DOI and Dynamic Aviation showed that a functional maintenance test flight was to be performed at the contractor's expense before the airplane resumed service. The DOI's Aviation Safety Manager explained that bureaus sometimes lent pilots to get aircraft back in service, with procedures that tried to operate like a FAR 135 operation. A review of DOI Operational Policy Memorandums (OPMs) revealed no guidance pertaining to test flights, and no single operations manual was mandated for pilots to carry.
On September 30, 2008, NBC-AMD advised that DOI aviation services contracts did not provide for government personnel to participate in off-contract operations. Subsequently, NBC-AMD took corrective actions including clarifying contract language, developing a process for off-contract operations, educating personnel, publishing a Lessons Learned Bulletin, revising contractual language to allow limited maintenance flights, and beginning work to require fleet pilots to carry an Aviation Policy Handbook.