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Failure to use checklist leads to accident

By NTSB · September 20, 2021 ·

The pilot reported that, during the takeoff roll at the airport in Lubbock, Texas, at about 60 knots, the Beech 36 lifted off in a nose high attitude and the stall warning horn actuated. About 20 feet above the ground, the airplane rotated to the right, but he overcorrected, and the left-wing tip hit the runway.

He landed the airplane without further incident.

The airplane sustained substantial damage to the left wing.

The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.

The automated weather observation station on the airport reported that, about 15 minutes before the accident, the wind was 230° at 9 knots. The pilot reported the wind was calm. The airplane departed from Runway 35L.

The pilot added that the elevator trim was found set to nose high, and that he should have used a pre-takeoff checklist to verify the elevator trim was set to the takeoff position.

Probable Cause: The pilot’s improper pitch trim setting during takeoff in a left quartering tailwind, which resulted in the airplane abruptly pitching up and subsequently experiencing an aerodynamic stall. Contributing to the accident was the pilot’s failure to follow a preflight checklist and verify that the elevator trim tab was in the takeoff position.

NTSB Identification: 100411

This September 2019 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. CJ says

    September 21, 2021 at 6:49 pm

    The accident victim may not have been the owner, but he surely wasn’t ready to fly that day either.

  2. Remo says

    September 21, 2021 at 8:22 am

    How about lowering the nose I’m not saying ignore the checklist but when something unusual happens you should know what to do

    • CJ says

      September 21, 2021 at 6:45 pm

      Like “Bob Hoover” always said, FLY the Plane, Fly the plane and fly the plane!

  3. Warren Webb Jr says

    September 21, 2021 at 6:52 am

    Agree with all comments, but wonder if the airplane wasn’t already showing the out of trim condition on the takeoff roll with a higher than normal pitch. I can understand where on a nice day there isn’t a lot of control input, but the takeoff roll and rotation are very critical points where the pitch should be positively controlled with the hand on the control wheel/stick – no over-relying on the trim. An out of trim condition in a single can normally be felt as soon as the power is applied.

  4. Jerry King says

    September 21, 2021 at 6:45 am

    I may be a bit anal, but in addition to my PREFLIGHT checklist, I also have a SHUTTDOWN checklist to insure everything where it is supposed to be and install covers, etc. This helps to insure NO SURPRISES. Both checklists are tailored to my specific aircraft and laminated back-to-back.

  5. Dan says

    September 21, 2021 at 6:37 am

    CIGARTIPPS

    Controls – free & clear
    Instruments – in green and set
    Gas – fuller tank
    Altimeter – set
    Radios – check / recheck / atis (hear) and com
    Transponder – set
    Trim – takeoff
    Ignition – mags / carb heat
    Prop – full takeoff pwr set
    Pump- fuel pump on
    Seatbelts – secure

    Runway clear

    Hhmmm did I forget one? Do it again!

  6. geebig says

    September 21, 2021 at 5:37 am

    Yes. Resetting aileron and elevator trim to neutral from the last flight is on a complete preflight checklist. The item is usually after arriving at the runnup area, setting the parking brake and just before checking flight controls are free and clear.

  7. Contrary says

    September 21, 2021 at 5:12 am

    All an accident investigator has to do is see the same old reports and change the names. Use the rules and procedures set forth and you’ll most likely have a safe flight.

  8. JimH in CA says

    September 20, 2021 at 2:59 pm

    A checklist for this is not required., but I do check this 3 times.!

    1 -When I open the pilot door, [ Cessna ], while standing at the door, I reach between the seats and check the fuel selector, pull on the flaps, [ Johnson bar], and look at , and set the elevator trim to the ‘takeoff’ setting…match the 2 white lines, which sets the trim at ‘neutral’.
    2 -Then, during the pre-flight walk around, at the tail, while checking the elevator hinge points, make sure that the trim tab is fared with the elevator [ neutral position].
    3. during my run up, I check the flaps, fuel and the trim one last time.

    The trim in a bonanza is probably in a different location, but the process can be the same.

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