NTSB Final Report Cites Incorrect Rudder Input In Addison, Texas, King Air Crash


The NTSB’s final report this week on the June 30, 2019, fatal crash of a Beech King Air 350 at Addison Airport in Texas concludes that the pilot likely depressed the wrong rudder pedal in his attempt to maintain control after loss of thrust in one engine. After noting that evidence indicated the King Air’s left engine thrust dropped off to near zero several seconds after rotation, the NTSB wrote, “Based on an evaluation of thrust estimates provided by the propeller manufacturer and performance data provided by the airplane manufacturer, it is likely that the pilot applied left rudder, the opposite input needed to maintain lateral control, before applying right rudder seconds later. However, by then, the airplane’s roll rate was increasing too rapidly, and its altitude was too low to recover.”

Supporting its conclusion that the pilot initially applied the wrong rudder input, the board wrote, “During the first five seconds after the propeller speed deviation, the airplane’s roll rate was about five degrees per second to the left; its roll rate then rapidly increased to more than 60 degrees per second before the airplane rolled inverted.”

Citing the cockpit voice recorder findings, the board also criticized the crew for failing to complete pre-takeoff checklists. For example, as to what caused the power to drop off on the left engine, “the NTSB noted that there was a known risk of an unintentional movement of an engine power lever if its friction lock was adjusted incorrectly. Friction lock settings are one of the items in a pre-takeoff checklist the pilot failed to use,” according to a statement from the board.

The privately owned and operated King Air was departing Addison on a flight to St. Petersburg, Florida. Both pilots and all eight passengers died in the fiery crash into the side of a hangar.

Mark Phelps
Mark Phelps is a senior editor at AVweb. He is an instrument rated private pilot and former owner of a Grumman American AA1B and a V-tail Bonanza.

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  1. It would be helpful to provide a clickable link to the NTSB report in articles such as this one. The NTSB’s CAROL is not exactly user-friendly.

  2. When I first got my multi-engine rating in the 70s I was taught dead foot, dead engine, working foot ,working engine. The problem with that is you might start using it as a guide to figure out which rudder to step on, which could make you step on the wrong rudder as you go thru the little jingle under a stressful situation. Later I received better training, which included not even identifying which engine failed. Just fly the plane. Lower the nose to maintain speed and hold the wings level with the ailerons. Then apply rudder to hold the heading or stop the yaw. Lowering the nose is critical. You do not want to stall or get below VMC air. The faster you are the easier it is to control. Next trim the rudder. Now the plane is stable. Turn on the auto-pilot if you have one.
    If at any time you find yourself using full rudder or full aileron you have reached your minimum control speed. Lower the nose to gain speed and get more control so your rudder or ailerons inputs are not at their limits. Going faster always makes you more stable.
    After it is stable you can start evaluating which engine has failed. I eventually came to the conclusion that working foot working engine was just one more distraction you don’t need.
    In 1985 Midwest Express Airline Flight 105 lost a DC-9 right after takeoff with almost an engine failure. Just like this King Air they did not lower the nose and hold wings level and use the rudder to control the yaw. Everyone on board perished.

    • I’m kinda with you on that,dead foot thiing was mostly a distraction. When I too a Multi CFI check ride in an A65 Queen Air. i did all right by the book, repeating check lists like all required. Flew it by the numbers ( a simulated g arould with an immediate eingine failure), and that doggy Queen Air slowly settled right back into the simulated ground. but I did it right by the book, airspeeds, etc. The old time GADO inspector said what the hell are yo doing, we crashed. I said but we crashed by the book Sir. He said I’m going to give you one more chance but this time just fly the airplane. We started the go around again and he failed the engine. We started to sink slowly just like before. I was at blue line. He said pull back o the yoke and get it climbing again. I did some. The plane did keep flying. He said do it some more. I did. He prompted me several more times until the speed was getting down near VMC..but I was in complete control, and we were actually climbing slowly. He made me do it again without him prompting and I passed. He said screw all that memorized stull and the numbers. Just fly the damn airplane!
      We did have at my last airport, a King Air crash right after takeoff when an engine failed. Although the plane should have flown just fine, flying it straight ahead, he tried to do an immediate turn back to the airport and VMCed ,I guess, right into the airport property. It was concluded he also had a throttle friction lock not lock and the throttle crept back on him. I would have thought that right after takeoff his hands would have still been on the throttles.

  3. About 2 yrs ago, a DC3 was videoed showing just as the tail lifted (on take off) the craft veered off to the left & crashed into a building killing everyone.
    Like MANY incidences like this, I NEVER see a follow up report.
    I believe someone said it belonged to an institution like the CAF.
    Anyway, the above article reminded me of the DC3.
    Hopefully someone out there has some knowledge of this. Thanks Bob

    • I now remember that I think no one was hurt, but still wonder if he had pushed the wrong rudder.

    • I was just going to post about the rudder boost. It is a good system, but the when it activates, the rudder pedal on the good side actually pushes back against your foot, and it can cause an initial confusion of which engine has failed. Dead foot, dead engine does not work that well on the King Air because of the rudder boost.

  4. Rudder boost does not push back against your foot on the good side in the event of an engine failure. For example, if the left engine fails, the airplane will try to yaw to the left. The rudder boost will apply right rudder ( the good side) to counteract the yaw. All you have to do is follow the rudder pedals with your feet and possibly apply more right rudder if necessary. If you can’t do this you shouldn’t be flying the plane.

  5. The PIC of this accident received high marks in training, yet went on to operate the aircraft, often brushing aside checklists as noted in the NTSB report. Negating W&B, and restricting FO/Right Seater’s from flying, only on flights without passengers. Not only did the PIC step on the wrong rudder at a moment of truth, he also failed to retract the gear or feather the prop. But the most fatal mistake, to me, is the fact that the engines indicated no post accident troubles. Leading investigators to believe the power levers and prop friction locks were not used, in haste.. Meaning, if someone were to take the time to notice, that the power levers were moving aft, and then push them back up. Eight people may still be alive, regardless of how crisp one’s emergency procedures might be when called upon..

    It’s a sum game, begging each of us to add every bit of knowledge and skill, at every opportunity. Attention to detail, slow and methodical, is the only way to truly open that “Safety Margin.”