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Accidents · NTSB CEN20LA352 · Final report

Beech 200 accident near Rockford, Illinois, August 20, 2020

On August 20, 2020 at about 8:42 pm local time, a 1984 Beech 200, registered N198DM, was destroyed in an accident during takeoff near Rockford, Illinois (Chicago/Rockford Intl airport). It was a positioning flight under general aviation rules (Part 91). 1 person was killed. The weather was visual conditions (good weather).

The NTSB's probable cause their words, unchanged

The pilot’s failure to maintain airplane control following a reduction of thrust in the left engine during takeoff. The reason for the reduction in thrust could not be determined based on the available evidence.

Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.

What the record shows

Date
August 20, 2020 · about 8:42 pm local time
Place
Rockford, Illinois · Chicago/Rockford Intl · map
Type
Accident
Injuries
1 person was killed.
Weather
visual conditions (good weather)
Aircraft
Beech 200 B200, built 1984 · all 200s on the register
Registration
N198DM · no longer on the register · serial BB1198
Damage
Destroyed
Flight
Positioning flight · general aviation rules (Part 91)

The NTSB's narrative final · quoted from the NTSB record

The pilot departed on a positioning flight in the twin-engine airplane. Videos recorded by multiple airport-based cameras showed the airplane take off from runway 19. Shortly after liftoff, the airplane started turning left, and the airplane developed a large left bank angle as it was turning. The airplane departed the runway to the left and impacted the ground. During the impact sequence, an explosion occurred, and there was a postimpact fire. An airplane performance study showed that during the takeoff, a nose-left sideslip, a left side force, and a left roll occurred, consistent with the loss or reduction in thrust of the left engine. The sideslip was reduced, likely due to inputting rudder to balance the side force, and the airplane briefly rolled right possibly due to an overcorrection in rudder. The airplane pitched up and was able to begin climbing again; however, it continued to lose speed. The sideslip then reversed, and the airplane rolled left again before impacting the ground. The study indicated that before rotating and lifting off, the airplane accelerated to a groundspeed of 98 knots (kts) and an airspeed of 105 kts, which was about 19 kts above the published minimum control speed for the airplane. Therefore, the airplane had achieved sufficient airspeed for the pilot to maintain control despite a loss or reduction in left engine thrust provided he made the appropriate control inputs. The sideslip force calculations indicated that there was a partially successful attempt to maneuver the airplane back to level flight when the airplane rolled back right, but it was not maintained. The right rudder input would need to be held until the thrust asymmetry was corrected. Teardown examinations of the engines and propellers found no evidence of preimpact failure. Both engines exhibited evidence of operation at impact. Damage to the propeller blades and hubs indicated that neither propeller was feathered at impact. The predominant left propeller blade bending and twisting was aft and toward low pitch. The predominant right propeller blade bending and twisting was forward in the thrust direction and toward high pitch. Analysis of the propeller internal witness marks and the blade damage found that the right engine was producing more power than the left engine at initial impact. Based on the available evidence, it could not be determined why the left propeller was not feathered at impact, even though the autofeather system was armed. The rudder trim knob was found 4 units to the left; the aileron trim knob was found 6 units to the right; and the rudder boost switch was found in the OFF position. The before engine starting checklist in the pilot’s operating handbook for the airplane specified that the rudder and aileron trim be set and that the rudder boost switch be on. Therefore, the postaccident positions of the rudder trim knob, aileron trim knob, and rudder boost switch likely indicate the pilot did not follow the before engine starting checklist. With the rudder boost switch not being on, it could not be determined based on the available evidence, what role that system may have had with the pilot attempting to maintain control of the airplane during the asymmetric thrust sequence. Although the pilot’s previous history of significant coronary artery disease and the scar in his left ventricle placed him at increased risk of an acute cardiac event, whether such an event occurred at the time of the accident could not be determined from the available information. Absent evidence of an engine malfunction, the investigation considered whether the left engine’s thrust reduction was the result of a malfunction in the throttle control system or an uncommanded throttle movement due to an insufficient friction setting of the airplane’s power lever friction locks. However, heavy fire and impact damage to the throttle control system components, including the power quadrant and cockpit control lever friction components, precluded determining the position of the throttle levers at the time of the loss of thrust or the friction setting during the accident flight. Thus, the reason for the reduction in left engine thrust could not be determined.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

The factual record from the NTSB's investigation tables, in plain English

What happened, in order

  1. Unknown or undetermined during takeoff
  2. Collision during takeoff/land during takeoff
  3. Runway excursion during takeoff
  4. Loss of control in flight during takeoff defining event
  5. Explosion (post-impact) during post (impact)
  6. Fire/smoke (post-impact) during post (impact)

The NTSB's findings

  • Not determined › Not determined › (general) › (general) › Unknown/Not determined
  • Personnel issues › Task performance › Use of equip/info › Aircraft control › Pilot
  • Aircraft › Aircraft oper/perf/capability › Performance/control parameters › Altitude › Not attained/maintained
  • Aircraft › Aircraft oper/perf/capability › Performance/control parameters › Lateral/bank control › Not attained/maintained

Pilot

  • Certificate: private
  • Ratings: multi-engine land; single-engine land; instrument: airplane
  • Flight time: 3,650 hours in all
  • Last flight review: November 15, 2019
  • Medical certificate: Class 3 (with waivers/limitations)
  • Seat: left
  • Injury: fatal

The aircraft

  • Airframe total time: 8,018.9 hours
  • Last inspection: continuous airworthiness programme, August 20, 2020; 0 hours since
  • Maximum gross weight: 12,590 lb
  • Seats: 8
  • Landing gear: retractable
  • Engine 1: Pratt & Whitney Canada PT6A-42 (turboprop); 8,009 hours total
  • Engine 2: Pratt & Whitney Canada PT6A-42 (turboprop); 8,076 hours total
  • Fire on the ground

The flight

  • Departed from: RFD Rockford IL at 8:41 pm
  • Destination: DPA West Chicago IL
  • Flight plan: none
  • Runway 19, 8,200 ft by 150 ft

Weather at the time

  • Light: daylight
  • Wind: from 200° at 9 knots
  • Visibility: 10 statute miles
  • Sky: scat at 25,000 ft
  • Temperature: 82°F (28°C), dew point 55°F (13°C)
  • Altimeter: 29.97 inHg
  • Observation at 2:54 pm from KRFD

Weather report (METAR): KRFD 201954Z 20009KT 10SM SCT250 28/13 A2997 RMK AO2 SLP144 T02830133

Injuries

FatalSeriousMinorNone
Flight crew1

Documents from the investigation the NTSB's docket: the evidence folder behind the report

38 documents, released by the NTSB on December 20, 2022. View them here, or download them; the NTSB redacts some personal details before release, and this site shows the NTSB's own titles rather than its file names.

#DocumentWhat it is
1 Accident Photographs PDF, 12 pages View Download
2 Accident Site Diagram and Cockpit Photographs (Courtesy of Textron Aviation) PDF, 5 pages View Download
3 Various Statements PDF, 6 pages View Download
4 Pilot's Recent Logbook Entries PDF, 13 pages View Download
5 Pilot's Initial and Most Recent Training Certificates - Beechcraft B200 PDF, 2 pages View Download
6 Airplane Flight Log and Weight and Balance Sheets PDF, 23 pages View Download
7 Weight and Balance Calculations PDF, 4 pages View Download
8 Airframe Maintenance Records PDF, 15 pages View Download
9 Left Engine and Left Propeller Maintenance Records PDF, 17 pages View Download
10 Right Engine and Right Propeller Maintenance Records PDF, 19 pages View Download
11 Engine Trend Monitoring Logs PDF, 3 pages View Download
12 Recent Maintenance Work Package and Fuel Receipt PDF, 42 pages View Download
13 NTSB Airframe Examination Report PDF, 6 pages View Download
14 Powerplants Group Chair's Factual Report PDF, 28 pages View Download
15 FAA Toxicology Report PDF, 1 page View Download
16 Global Positioning System (GPS) & Attitude Heading Reference System (Ahrs) Device - Specialist's Factual Report PDF, 11 pages View Download
17 Attachment 1 to Global Positioning System (GPS) & Attitude Heading Reference System (Ahrs) Device - Specialist's Factual Report data file Download
18 Video Study PDF, 4 pages View Download
19 Airport Video Footage # 1 (Courtesy of the Chicago Rockford International Airport) video View Download
20 Airport Video Footage # 2 (Courtesy of the Chicago Rockford International Airport) video View Download
21 Airport Video Footage # 3 (Courtesy of the Chicago Rockford International Airport) ASF file Download
22 Airport Video Footage # 4 (Courtesy of the Chicago Rockford International Airport) ASF file Download
23 Airport Video Footage # 5 (Courtesy of the Chicago Rockford International Airport) ASF file Download
24 Airport Video Footage # 6 (Courtesy of the Chicago Rockford International Airport) ASF file Download
25 Aar - Video Footage (Courtesy of Aar) video View Download
26 Bergstrom - Video Footage (Courtesy of Bergstrom) video View Download
27 Aircraft Performance Study PDF, 8 pages View Download
28 Textron Aviation - Flight Simulator Information PDF, 1 page View Download
29 N198DM - Opsvue Data (Google Earth) map file Download
30 N198DM - Opsvue Data (Microsoft Excel) data file Download
31 N198DM - Opsvue Data (Playback) video View Download
32 N198DM - ADS-B Data (Google Earth) map file Download
33 N198DM - ADS-B Data (Microsoft Excel) spreadsheet Download
34 Beechcraft B200 POH and AFM Excerpts PDF, 11 pages View Download
35 Various King Air Magazine Articles PDF, 28 pages View Download
36 ATSB Safety Advisory Notice - Power Lever Friction Lock Adjustment PDF, 2 pages View Download
37 NTSB Wreckage Release Form PDF, 2 pages View Download
38 NTSB Party Member Forms PDF, 2 pages View Download

The same docket at the NTSB · documents without a copy here are fetched from the NTSB when you open them.

Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.