- Date
- August 6, 2001, 11:45 local (19:45 UTC)
- Place
- Cooper Landing, AK
- Injuries
- 2 serious, 2 uninjured
- Damage
- Substantial damage
- Phase of flight
- Enroute
- Aircraft
- N813SPCessna 172S
- Weather
- Visual (VMC) · Day
- Status
- Completed · report July 15, 2002
- Report
- Approved by Office Director
- NTSB office
- Alaska Regional Office
- Parties
- FAA-AL-ANC FSDO 03, CESSNA AIRCRAFT COMPANY, AV ALASKA INC.
- FAA report
- 20010806040039A
- Case key
- 52949
From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.
On this page
Probable cause
The pilot's inadequate remedial action to disconnect the autopilot during an uncommanded altitude deviation while in cruise flight. Factors in the accident were activation of the autopilot; the pilot's lack of familiarity with the airplane's autopilot system; her failure to attain the proper touchdown point during an emergency landing, and delayed go-around resulting in an overrun and collision with trees; the operator's insufficient training standards for the airplane, and the pilot's flight instructor's failure to provide adequate upgrade/transition training in the airplane.
Sequence of events
NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.
Analysis
The private certificated pilot was on a personal sightseeing flight in a rental airplane. The pilot had limited experience in the airplane that was equipped with an intergrated flight/nav/autopilot system. During cruise flight, the airplane suddenly pitched upward. The pilot pushed forward on the control yoke, and noticed the trim wheel moving in a nose up direction. She used the manual trim wheel to trim the airplane nose down, but the airplane still pitched upward. The pilot began to exert forward pressure on the control yoke to keep the airplane from climbing, and asked her front seat passenger to help push forward on the control yoke. The pilot made a "mayday" call and decided to make an emergency landing at a 2,200 feet gravel surface airport. The pilot said she turned onto about a one mile final approach, but said she was either going too fast, or the runway was too short. The airplane touched down about mid-length on the runway and bounced several times. The pilot saw the end of the runway approaching, and added full throttle to begin a go-around. The airplane collided with trees at the departure end the runway. The pilot said she did not know if the autopilot was on or off, but she did not consciously select or use the autopilot, and did not even know if the airplane was equipped with electric trim. The pilot said she remembered seeing 7000 displayed in a box located above the transponder (the autopilot computer). The pilot said she used the radio transmit button on the left side of the pilot's control yoke, but did not use any other switches on the yoke. The pilot said her front seat passenger is not a pilot, and did not touch any items on the control panel. The autopilot was installed on the right side of the instrument panel. The pilot did not receive any instruction from the operator, or from her flight instructor about the autopilot system, and the pilot did not familiarize herself with the autopilot system. The pilot's flight instructor reported that during a previous training flight with another student, he discovered the autopilot system was on, even though he did not turn it on. Postaccident testing of the autopilot system did not reveal any malfunction.
Factual narrative
History of flight
On August 6, 2001, about 1145 Alaska daylight time, a Cessna 172S airplane, N813SP, sustained substantial damage during a precautionary landing at the Quartz Creek Airport, located about 3 miles east of Cooper Landing, Alaska. The airplane was being operated as a visual flight rules (VFR) local area personal flight when the accident occurred. The airplane was registered to Av Alaska Inc., Anchorage, Alaska, and operated by the pilot. The private certificated pilot and one passenger received serious injuries. Two other passengers were not injured. Visual meteorological conditions prevailed. A VFR flight plan was filed. The flight originated at the Ted Stevens Anchorage International Airport about 1100.
According to information provided by an Alaska State Trooper, and information provided by a witness at the Quartz Creek Airport, the accident airplane was observed to touch down about mid-length on runway 21 and bounce several times. The airplane then collided with trees beyond the departure end of the runway, and came to rest next to a boat launch ramp in an adjacent campground. At the accident scene, the airplane was resting upright on its main landing gear, but nose down, with the nose wheel strut displaced forward, under the engine. The engine cowling was torn off the fuselage. The right wing separated from the fuselage at its rear attach point, and the wing was displaced forward from the fuselage.
In a telephone interview with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on August 10, the pilot reported that during the flight, the airplane suddenly began climbing. She said she used the manual trim wheel to trim the airplane nose down, but the airplane still pitched upward. She pushed forward on the control yoke in an attempt to counter the upward pitch. She said she did not know if the autopilot was on or off, but she did not consciously select or use the autopilot, and she said she did not know if the airplane was equipped with electric trim. She headed for the Quartz Creek airport, and bounced twice on the runway. The wheels collided with trees at the end of the runway.
During an in-person interview with the NTSB IIC on August 15, the pilot reported that after departing Anchorage, the airplane was in cruise flight about 3,000 feet msl near Kenai Lake. During the flight, the airplane suddenly began to pitch upward, climbing about 600 feet per minute. The pilot said she pushed forward on the control yoke to return to 3,000 feet msl, and noticed the trim wheel moving in a nose up direction. The pilot began to exert forward pressure on the control yoke to keep the airplane from climbing, and she said she was concerned that the airplane might stall. She asked her front seat passenger to help push forward on the control yoke. The pilot made a "mayday" call on the airplane radio, and decided to make an emergency landing at the Quartz Creek airport. The pilot said she turned onto about a one mile final approach to runway 21, but was either going too fast, or the runway was too short. She said she saw the end of the runway approaching, and added full throttle to begin a go-around. The airplane collided with trees at the departure end of runway 21. She said she had lowered the flaps for landing, but raised the flaps for the go-around.
The pilot said she did not remember any annunciator lights on the instrument panel, but during the emergency, she did remember seeing 7000 displayed in a box located above the transponder. The pilot said she used the radio transmit button on the left side of the pilot's control yoke, but did not use any other switches on the yoke. She reiterated that she was not aware the airplane had electric trim. The pilot said her front seat passenger is not a pilot, and did not touch any items on the control panel.
During an interview with the NTSB IIC, the front seat passenger reported that during their flight, the pilot suddenly told everyone to be quiet. The pilot was having trouble controlling the pitch of the airplane, and appeared to be attempting to trim the airplane by the use of a trim wheel. She was asked by the pilot to help push on the control yoke. She remember seeing a small landing strip in the area, but did not remember anything else until being placed in an ambulance.
Personnel information
The pilot holds a private pilot certificate with an airplane single-engine land rating. The most recent third-class medical certificate was issued to the pilot on December 15, 2000, and contained the limitation that the pilot must have available glasses for near vision.
According to the information contained in the Pilot/Operator Report (NTSB Form 6120.1/2) submitted by the pilot, the pilot's total aeronautical experience consists of about 230 hours, of which 220 were accrued in the accident airplane make and model. In the preceding 90 and 30 days prior to the accident, the report lists a total of 10.5 and zero hours, respectively.
The pilot reported she utilized the accident airplane for several instrument training flights and for personal use, and had accrued about 6 hours in the accident airplane (Cessna 172S). She said she was familiar with the electronic HSI and the moving map on the multifunction display. When she was receiving instrument flight training from an instrument instructor, she said she did not use the autopilot system, and was not provided with any familiarization with its function or controls. She said she was not aware the airplane had an electric trim system. The pilot said she was not provided with any training or a check out on the autopilot or electric trim system from the operator. She said that during personal flights, she did not intend to use the autopilot system, and had not familiarized herself with its functions or controls.
Aircraft information
The airplane and engine had accumulated a total time in service of 333.4 hours since new. The airplane was maintained on an approved airworthiness inspection program (AAIP). The most recent inspection was accomplished on July 25, 2001, 38.2 hours before the accident.
The operator added the airplane to its fleet of rental airplanes in February, 2001. The airplane was equipped with a Honeywell KAP 140 two axis autopilot with altitude preselect, a Bendix/King transponder, dual Bendix/King KX 155A Nav/Comm radios, a Honeywell KLN 94 GPS navigation computer. The accident airplane was used for rental customers, and as a training airplane for students.
In March, 2001, additional equipment was installed in the airplane, including a Sandel Avionics SN 3308 Navigational Display, and a UPS Aviation Technologies, MX20 multifunction display as part of an FAA Capstone navigation/terrain and radar tracking demonstration project. The airplane's center radio/navigation stack was modified from its standard instrument panel installation to accommodate the installation of the multifunction display at the top of the center panel radio stack. The Honeywell KAP 140 autopilot computer, normally positioned at the bottom of the radio stack, and the airplane's transponder, were both moved to the right of the center stack. The autopilot was positioned in the center of the right side of the instrument panel, above the transponder, both in front of the right seat position.
The KAP 140 autopilot system consists of a computer/controller, interconnected to the GPS and navigation system displays, pitch and roll actuator servos, control yoke switches, and an electrical system, pull-type, circuit breaker. It provides an autotrim feature during autopilot operation, and manual electric trim when the autopilot is not engaged. The airplane also retains a manual trim wheel. The features of the autopilot system include a vertical speed mode, altitude hold, wing level, heading select, approach, ILS coupling to a localizer and glideslope, backcourse mode, altitude al
Aircraft
- Registration
- N813SP
- Reported as
- Cessna 172S
- Category
- Airplane
- Serial number
- 172S8723
- Airframe hours
- 333.4
- Engine
- Lycoming IO-360-L2A, 180 horsepower, reciprocating
- Damage
- Substantial damage
- Flight
- Personal · Part 91
- Operator
- Erin H. Meade
- Registered owner
- Av Alaska Inc.
- Airworthiness certificate
- Standard, Normal
- Last inspection
- AAIP · July 25, 2001 · 38.2 hours before
- Departed
- PANC · Anchorage, AK
- Destination
- AK
- Flight plan
- VFR
- Airport
- JLA · Quartz Creek, runway 21, 2,200 × 60 ft, gravel
Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.
Flight crew
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot
- Age
- 48
- Injuries
- Serious
- Certificate
- Private
- Airplane ratings
- Single-engine land
- Medical
- Class 3, Valid Medical--w/ waivers/lim
- Last flight review
- November 22, 2000
- Seat
- Left
- Flight hours
- 230 total · 220 in this make and model · 113 as pilot in command · 11 in the last 90 days
Weather
- Conditions
- Visual (VMC) · Day
- Wind
- Calm
- Visibility
- 9 statute miles
- Lowest ceiling
- None
- Temperature
- 64 °F, dew point 48 °F
- Altimeter
- 30.06 inHg
- Observed at
- PASX, 38 nm away
FAA reports on this event · 1
The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.