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First flight after restoration fatal for pilot

By NTSB · April 10, 2019 ·

The accident flight was the Piper PA-12’s first flight after undergoing restoration over the course of two years.

Although the mechanic who had worked on the airplane with the pilot wanted the pilot to do a high-speed taxi test before flight, the pilot wanted to “hurry up” and test fly the airplane as he had a friend visiting and wanted to take him flying in the airplane.

During the takeoff, witnesses observed the airplane pitch up into a nose-high attitude just after liftoff, stall, and descend in a nose-down attitude to hit the ground at the airport in Sanford, Florida. The pilot died in the crash.

Examination of the wreckage revealed crush damage to the nose and the leading edges of the wings that was consistent with a nearly vertical nose-down flight path at the time of impact.

Further examination of the wreckage revealed that the airplane’s elevator control cables were misrigged, such that they were attached to the incorrect (opposite) locations on the upper and lower ends of the elevator control horn, resulting in a reversal of elevator control inputs. If the pilot had checked the elevator for correct motion during the preflight inspection and before takeoff check, he likely would have discovered that it was misrigged, and the accident would have been avoided.

Probable cause: The incorrect rigging of the elevator control cables, which resulted in a reversal of elevator control inputs applied by the pilot during the takeoff, an excessive nose-high pitch, and subsequent aerodynamic stall after takeoff. Also causal was the inadequate postmaintenance inspection and the pilot’s inadequate preflight inspection and before takeoff check, which failed to detect the misrigging.

NTSB Identification: ERA17FA148

This April 2017 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.

About NTSB

The National Transportation Safety Board is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation, including railroad, transit, highway, marine, pipeline, and commercial space. It determines the probable causes of accidents and issues safety recommendations aimed at preventing future occurrences.

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Comments

  1. Chris White says

    April 29, 2019 at 5:45 am

    I don’t normally comment, I just want to thank you for publishing…good reminders that no one is above making simple costly mistakes. Control checks are not rocket-science, checklists remain important. Tuning in your mind to the task at hand can at times be critical and are part of situational awareness whether you’re a mechanic or a pilot. Sad for loss we don’t want to think we can do something like this, but. 47 years ago I started learning to fly. Still learning valuable lessons and appreciate the reminders of the simpler things that bite.
    I’m a CFI(I) ASEL, A&P. I work in the aviation training industry and own and fly a Pitts S2A and a 1946 Ercoupe …and I occasionally make mistakes I’d like to think I would never make, usually when I get saturation overload or deadline anxiety.

  2. John Robertson says

    April 27, 2019 at 9:07 am

    An account of this tragedy was published for the education and warning of the consequences of inadequate control maintenance, inspection and pre-flight checks. It should not be a forum for blaming, disparaging and incivility; that defeats it’s purpose. Some of these posts appear to violate General Aviation News Comments Policy. Why are they allowed?

    • Dale L. Weir says

      April 30, 2019 at 10:20 am

      Your comments are spot on. Unfortunately there are the usual suspects who believe that these articles are a forum to impress us with their superior knowledge and skill. I like to think of myself as a high time student pilot, there is still a lot to learn.

  3. Dennis says

    April 27, 2019 at 6:02 am

    Attacking the messengers and sugar coating politically correct excuses won’t bring the pilot or the aircraft back, or more importantly, drive the lesson home. Anytime anybody works on any part of the machine check all the controls. Both he and his “mechanic” made an unforgivable AND undeniably stupid error that resulted in a wrecked aircraft and a dead pilot. Incidentally, his acceptance to the AF Academy proved he had excellent test scores; his failure to perform a simple preflight speaks to his judgment. “The truth is incontrovertible. Malice may attack it, ignorance may deride it, but in the end, there it is” — Winston Churchill

  4. Ernest Hendrickson says

    April 27, 2019 at 4:31 am

    It’s not rocket science. EVERYTIME I sat at the end of the runway ready to take off I cycled the rudder pedals. Cked the elevators TWICE while observing their movements. Okay? Never a problem. QED

  5. CJ Gerker says

    April 25, 2019 at 4:16 pm

    Piper has for years never marked their cable ends of the older rag PA and J series aircraft. The cables don’t have reverse threads to prevent them from being mixed. A J5 in Wichita caught a pilot off guard from McConnell AFB and it bit him too. The control check on the ground with a witness if necessary is the way to go. A high speed taxi don’t do much.

    • Stefan says

      April 25, 2019 at 5:10 pm

      While not the best engineering it still would have been easily seen with a simple control check… pull back elevator goes up. Takes mere seconds to check all controls.

  6. Sarah A says

    April 11, 2019 at 7:40 pm

    There were several chances for this error to have been caught and corrected it is just sad that neither the mechanic, the IA (if different) and even the pilot never bothered to run that simple Controls Free and Correct check. So one less airplane in the fleet, one less active pilot and one more blot on the GA accident record.

  7. Joe Henry Gutierrez says

    April 11, 2019 at 2:05 pm

    It would seem to me that if the elevator controls cables were misrigged, when the pilot pulled back on the control stick the aircraft would of wanted to nose over because the elevator would of deflected down thus raising the tail and lowering the nose, right ?? So in order to take off, he would of needed to push the control forward in order to rotate..correct ? If in fact that was the case, why did he continue rolling down the runway in an effort to try and take off ? Just don’t make no sense….Duhhh

    • Dave Gerker says

      April 27, 2019 at 4:55 am

      The victim (pilot) probably thought by pushing forward on the control stick the nose would and should have gone down. Cross rigged controls just made it worse. New of a guy in Michigan that had miss rigged a 1200 hp Thrush agplane throttle….. Starting it first time after conversion to the big engine, she fired up and went full throttle…. Took a lot of balls to push forward on the throttle, but he did and it slowed and settled down. He knew immediately what happened.

    • Stuart Matthews says

      April 27, 2019 at 7:12 am

      At full throttle and accelerating the pilot probably pushed the stick forward to lift the tail then noticed it tried to climb, and then pushed the stick further thinking the airplane would level, but instead it climbed more. Then panic mode set in, he may have aggressively pushed the stick further forward resulting steep climb and then it stalled.

    • Joe Greulich says

      April 27, 2019 at 9:12 am

      What if he was thinking I need to hold it down and it lifted off and then more nose down to control airspeed , he was completely faked out .

  8. SCOTT says

    April 11, 2019 at 11:17 am

    Just plain sad. Who was the A&P / IA that signed off the aircraft as airworthy? What PIC does not do a CS check before flight, especially first flight? These type of accidents aren’t not as infrequent as we’d like to believe and not limited to individuals.
    http://www.aero-news.net/index.cfm?do=main.textpost&id=a03a3c8c-9ba1-413f-9a0f-5a4ed2e5730e

  9. Henry K. Cooper says

    April 11, 2019 at 6:14 am

    A pilot is dead, and that’s a damned shame, but this accident would have been so easy to avoid. What mechanic wouldn’t check control surface deflection and movement after the work was done? How could the mechanic sign off the work in the logs and return the aircraft to service as airworthy? After a two-year restoration, what pilot could be so antsy to fly that an extra five minutes during a preflight inspection (if one was even accomplished) could not be spent?

    I recall about 30 years ago a Cessna 310 augured in after some heavy maintenance due to cross-rigged ailerons.

    Anyone can make a mistake during maintenance, but that is, in part, what inspections and that “second pair of eyes” is for.

    It is all so blatantly avoidable.

  10. gbigs says

    April 11, 2019 at 6:05 am

    “hurry up” Nothing more need be said.

  11. Ernest Hendrickson MD says

    April 11, 2019 at 5:27 am

    Low IQ leads to death. When I sit ready to take off I carefully ck to be sure the rudder ailerons etc are working correctly. Twice. This fool didn’t do this simple test. Also high speed taxi would have revealed the problem. And why didn’t he have other pilots ck it out? Obviously a foolish man with little understanding of how dangerous flying can be. Very sad.

    • Frank says

      April 18, 2019 at 3:39 am

      It just amazes me that people can be such ass h**ls and have the audacity to call someone dumb. Let me tell you chef it could and does happen to professionals all around the globe. What makes you so special, probably a weekend pilot with a few thousand hrs.

      You do know why something like this is called an accident, because that is what it t is, can happen to anyone, a 200 hr or 9000 hr pilot.

      And to call a dead pilot stupid, nice going there champ.

      • Ernest Hendrickson says

        April 27, 2019 at 4:36 am

        Loud mouth. Was accepted into USAF Cadet Flight School!! Only the top brains get into that school. Retards like you have no chance whatsoever….

    • Bob says

      April 18, 2019 at 3:43 am

      Earnest,

      You are a pompous idiot, and do not what your talking about. I know, your the best pilot on the field, your the best of the best. But you know nothing .

      • Ernest Hendrickson says

        April 27, 2019 at 4:38 am

        Again. Accepted into USAF Cadet Flight School. What about you?

  12. Stefan says

    April 10, 2019 at 9:17 am

    Wow… how in the world do you not check CS’s? I understand rushing though and missing this during routine flying but after a restoration?

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