The purpose of the flight was to perform a local maintenance test flight to evaluate the Cessna 414’s autopilot performance. The pilot, who was also a mechanic, reported that, before the flight, he removed and then reinstalled the S-TEC autopilot mode control unit in the cockpit due to a discrepancy reported on a previous flight.
He told investigators that, after a normal taxi and “complete run-up” at Joseph A. Hardy Connellsville Airport (KVVS) in Pennsylvania, he initiated the takeoff.
When the airplane reached rotation speed, he pulled back on the flight controls with one hand, but the flight controls did not move. He then pulled back on the flight controls with both hands, but the flight controls still did not move.
The passenger, who was also a mechanic, reported that the pilot was unable to rotate the airplane at rotation speed.
The passenger recalled that the runway surface had a dip in it and that he felt a “bump” about the time that he expected rotation to occur.
The pilot aborted the takeoff and applied maximum braking. The airplane was unable to stop on the remaining runway and ran off the runway and down a ravine.
The airplane subsequently collided with trees, which resulted in substantial damage to the airplane fuselage and wings.
The pilot sustained minor injuries while the passenger sustained serious injuries.
The pilot reported that there was nothing “strange” with the flight controls during the run-up. The passenger recalled that the flight controls were functional before takeoff.
Post-accident examination of the cockpit panel revealed that the left avionics stack included a Garmin GNS 530 GPS and a Bendix-King KX-155 navigation/communication receiver. The avionics tray on the left side that held the KX-155 unit was found stuck within the opening area of the elevator bell crank.
When the flight controls were moved forward or aft, which also moved the elevator bell crank forward and aft, the controls would not move.
The trays in the left avionics stack were found sagging downward, and the avionics units would move downward when the front of the units were pushed by hand.
Further examination revealed that the bottom rearward portion of the KX-155 avionics tray was deformed and that the tray and the bell crank displayed significant scratching and metal polishing. When the avionics tray was removed from the bell crank movement area, the flight controls operated with a full range of movement.
The avionics trays holding the GNS 530 and KX-155 equipment were secured to the sheet metal on the front of the cockpit panel, but neither avionics tray had metal straps that secured the rear or sides of the tray to the airplane’s structure of the airplane. The KX-155 avionics tray had a metal strap on its left side that was not connected to any structure of the airframe. No other avionics trays had straps connected to the airframe structure.
A review of FAA airworthiness records revealed that the Garmin GNS 530 was first installed in the airplane in 2006. Review of the maintenance records starting in 2006 found no entries relating to the removal and reinstallation of the GNS 530 or the KX-155 unit.
The pilot/mechanic stated that he performed numerous inspections on the airplane starting in 2016. He added that, before the accident, he “didn’t even know to look for this” on avionics trays.
FAA Advisory Circular 43.13-2A, Acceptable Methods, Techniques, and Practices – Aircraft Alterations, Chapter 2, Radio Installations, stated in part the following: To minimize the load on a stationary instrument panel, whenever practicable, install a support between the rear (or side) surface of the radio case and a nearby structural member of the aircraft.
Probable Cause: The pilot/mechanic’s failure to properly secure two airplane avionics units, which resulted in the trays supporting the units to sag downward and become lodged in the movement area of the elevator bell crank during the accident takeoff.
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This May 2022 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.
Bad decision making again !!! There’s no end..
Lot of pure assumptions and what should have been checked when. Apparently there wasn’t an identifiable problem when the plane flew in. No reason to assume there was one when the takeoff role started.
And to determine as to when or how the strap issue occurred would just be finger pointing at this point.
How about a Preflight controls check. Simple Left, right, forward and back….It would have prevented the whole accident. Poor checklist procedures on top of poor maintance.
You are neglecting the event sequence which states that the interference condition seemed to take place as the aircraft was accelerating down the runway and “felt a bump”. This would be after a control check was performed.
Yes, a control check should be performed. Best time to do so is before beginning to taxi. And the observation should not only check free movement, but correct movement because it is possible in some aircraft to reverse the rigging. So the check should start with ‘left turn-right aileron down and left up’. Elevator rigging and free motion should be checked during the walk around- Standing on the ground, slowly move the yoke its full range while watching the elevator move correctly.
On one of my first solos and in the flying club Cherokee 140 I was training in, I felt a pronounced “bump” in the flight controls during my run up. When I pulled back on the yoke, it felt like something was obstructing my pull for up elevator and then I noticed one of the comms moving a bit in the panel. I stuck my hand under there and the back end of the radio was loose and resting on the flight controls! I taxied back to the tie down and my instructor where we had a club mechanic fix it and he did so with a large zip tie! Pretty sure that’s not a good long term fix🥺
I think I recall another incidence of this happening recently, can anyone confirm that? I don’t know that it was this plane, I think it might have been another. That would be very odd that two different planes were brought down by sagging avionics trays, but should be an item to check.
I don’t know about a/c “brought down”, but as someone involved in avionics maintenance beginning in 1972, it is in my experience that interference with either improperly installed trays or wiring harnesses was encountered a number of times. In one case, a less than competent mechanic had actually used a cable tie to secure a cable bundle directly to the controls in a Cherokee.
Yes, JeffO, a cable tie was used in my incident. Even as a newby student pilot, I questioned that repair.
A friend of mine just purchased a Cherokee 6 and after the first annual had 76 pages of maintenance complaints. She had only flown the plane 20 hours since purchased. My point is this…not every annual is a good annual just because it’s signed off.
A number of the overlooked defects were serious enough to cause a crash. Some involved avionics tray installation. The FAA was notified only to have them give a pass on investigating the incident. Not good.
So lucky that that second yank didn’t cause the controls to move backward, as the outcome would likely have been even worse. Frozen control, abort take off.
This is unacceptable.. did not follow mandatory installation instructions for the rack.. I know it’s hard to do this kind of work under the dash but there’s a reason to do it correctly and it appears to be obvious in this case… How many have looked at the install and didn’t correct it???
The “Dash”?