# NTSB ATL02FA010: Cessna 310Q, N7648Q, Winston Salem, NC, November 7, 2001 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 7, 2001, 11:18 local (16:18 UTC) - Place: Winston Salem, NC - Coordinates: 36.091667, -80.291664 - Nearby events: https://openairdocs.org/map.md?lat=36.0917&lon=-80.2917&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report May 30, 2003 - Report: Approved by Office Director - Parties: Federal Aviatiion Administration FSDO-05, Teledyne Continental Engines, Cessna Aircraft Company - NTSB case key (mKey): 53745 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL02FA010 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/53745/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=53745 - Page: https://openairdocs.org/ntsb/ATL02FA010 ## Probable cause Improper installation of the elevator trim tab control rod by maintenance personnel which allowed the control rod to disconnect and jam in the full up position (elevator full down) while in-flight. This resulted in a loss of directional control and subsequent impact with trees and terrain. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, takeoff - initial climb - maintenance,installation - improper, other maintenance personnel (cause) - flight control,elevator tab - disconnected (cause) - Loss of control - in flight, descent - uncontrolled - aircraft control - not possible, pilot in command (contributing factor) - In flight collision with object, descent - uncontrolled - object - tree(s) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - residential area (contributing factor) ## Analysis According to Air Traffic Control (ATC) Transcripts, the pilot departed runway 22 at the Smith Reynolds Airport at 1112, enroute to Centerville, Tennessee. At 1113, the pilot reported that he was returning with a problem. At 1116, the pilot reported that he was experiencing "a lot of down pressure on the yoke". The pilot subsequently experienced a loss of control and the airplane collided with a tree in a residential area. Examination of the elevator found a bolt and castellated nut missing on the elevator trim tab control rod at the trim tab jackscrew. There was no evidence that the bolt had broken or sheared as a result of impact forces. Examination of the forward trim tab push-pull rod clevis revealed that its dry, oxidized condition indicated that the attaching bolt was missing for an undetermined time prior to the accident, and that the damage to the trim tab push-pull rod indicated that it was in the full up position (elevator full down) at the time of impact. The airframe had accumulated 3,650 hours of total time at the time of the accident and had accumulated 35 hours since its last inspection when all the flight controls were removed, stripped, re-painted, balanced and re-installed. ## Factual narrative HISTORY OF FLIGHT On November 7, 2001, at 1118 eastern standard time, a Cessna 310Q, N7648Q, collided with trees and subsequently the ground in a residential area following a loss of control after takeoff from the Smith Reynolds Airport in Winston Salem, North Carolina. The airplane was registered to Quality Aircraft Sales LLC, and operated by the private pilot under the provisions of Title 14 CFR Part 91, and instrument flight rules (IFR). Visual meteorological conditions prevailed and an IFR flight plan was filed. The pilot was fatally injured and the airplane was destroyed. The flight was originating at the time of the accident. According to Winston Salem Tower Air Traffic Control (ATC) Transcripts, the pilot departed runway 22 at the Smith Reynolds Airport at 1112, enroute to Centerville, Tennessee. At 1113, the pilot reported that he was returning with a problem. At 1116, the pilot reported that he was experiencing "a lot of down pressure on the yoke". At 1117, the pilot requested runway 04, the controller cleared the pilot for a visual approach to runway 04 but received no response. At 1118, Winston Salem Tower reported that radar contact was lost. At 1120, Windston Salem Tower received a report from the local fire department that they had received a call that there was an airplane crash west of the airport. PERSONNEL INFORMATION The pilot held a private pilot certificate with ratings and limitations for airplane single and multi-engine land and instrument airplane's. At the time of the accident the pilot had accumulated 2,825 hours in all aircraft, 2,195 hours in multi-engine airplanes and 34 hours in the Cessna 310Q. The pilot's most recent third class medical certificate was issued on May 1, 2000, with no waivers or limitations. AIRCRAFT INFORMATION The Cessna 310Q, S/N 310Q0427, was manufactured and certificated in 1971. It was a six seat, twin engine airplane with tricycle retractable landing gear. Federal Aviation Administration (FAA) records revealed that the airplane was registered to the current owners on December 23, 1971. A review of the airplane's maintenance logbook found that on April 1, 2001, the airplane's total time was 3,615 hours. On that date, the airplane was painted, the interior was refurbished and the airplane underwent a 100 hour inspection. According to the logbook entry, all flight controls were removed, stripped, repainted and balanced prior to being reinstalled on the airplane. At the time of the accident, the airplane had accumulated an additional 35 hours for a total time of 3,650 hours. METEOROLOGICAL INFORMATION Weather at the time of the accident was reported by witnesses as clear. Greensboro Flight Service Station was reporting weather at 1054, as winds 320 at 4 knots, visibility 10 statute miles, sky clear, temperature 19 celcius, dew point minus 1 celcius, altimeter 30.29. Greensboro provided a special weather report at 1136, which reported winds as calm, visibility 10 statute miles, sky clear, temperature 21 celcius, dew point 1 celcius, altimeter 30.28. WRECKAGE EXAMINATION Examination of the accident site found that the wreckage debris was located in a heavily wooded residential area. The crash debris line extended through a wooded area on a heading of 055 degrees magnetic. The pitch angle from the first tree contact to the ground crater was approximately 60 degrees, and the roll angle was approximately 55 degrees left wing low. The left wing tip tank was near the first ground contact location. A piece of the cabin overhead was observed embedded in a tree to the left of the crash debris line. There was no fire. The aileron flight control system continuity could not be established due to impact damage. All aileron control cables, which were observed, were separated in a tension overload type separation. The aileron cables were attached over the sprocket in the control column and were continuous out to the right wing. The cables to the left wing were observed separated. The aileron trim tab was observed separated and loose in the wreckage distribution path. The rudder control cables were observed attached to the rudder and were continuous to the rudder pedals. The rudder trim control cables were observed attached over the sprocket and were continuous up to the cockpit area. All of the attachments observed in the flight control system were bolts with castellated nuts and cotter pins. The elevator trim tab actuator to rod end attachment bolt and castellated nut were not found in the wreckage. No damage was observed to the screw jack rod end. There was also no damage to the attachment holes in the trim tab actuator rod end. Damage was observed to the elevator forward spar and inside leading edge skin, which matched the actuator rod end. The elevator flight control cables were attached to the bell cranks at both ends. The forward elevator actuation tube rod end at the bell crank and the aft elevator control tube were observed separated. The rod remained attached to the left elevator torque tube. The elevator trim cables remained attached to the trim tab actuator and were observed attached to the trim wheel in the cockpit area. The elevator trim screw jack was observed past the full nose up trim position. All cabin seats were destroyed in the accident sequence, and all seat belts had separated from their attachment points during the impact sequence. Both main fuel tanks, tip tanks, and the auxiliary fuel tanks (wing bladders) were ruptured at the accident site. All of the fuel lines were separated from the engine. Both of the engine driven fuel pumps were removed from the engines and their drive couplings were intact. There was extensive damage to both engines. This damage precluded a determination of continuity of either of the engines. Both engines were separated from the airframe. Both propellers were separated from the engines. All propeller blades remained attached to their respective propeller hubs. There was significant twisting and leading edge damage to all of the propeller blades Examination of the left engine found the oil sump crushed, the number 2, 4, and 6 cylinders were cracked, the exhaust pipes were crushed, and the number 2, 4, 5, and 6, rocker covers were missing. The fuel pump was removed and the drive shaft was intact. The oil sump was removed and the camshaft and gears were intact. All connecting rods were attached, the crankshaft was intact, all counterweights were on their respective pins and the oil screen was free of contaminants. The spark plugs were gapped in accordance with manufacturers specifications. The crankshaft was broken at the flange. It was not possible to rotate the engine due to cylinder damage. The following items were found separated from the engine: the fuel control unit, vacuum pump, alternator, oil cooler, starter, both magnetos, intake tubes on the number 2, 4, and 6 cylinders and the propeller governor. The overall condition and visual examination of the engine and parts, did not reveal discrepancies which would have precluded normal operation prior to impact. Examination of the right engine found that the camshaft gear was bent, and the internal engine components would not rotate. The oil sump was removed and the camshaft was intact, the crankshaft was also intact, all connecting rods were attached, and the counterweights were all on their respective pins. The fuel pump was removed and the drive shaft was intact. The crankcase was broken in the forward lower area. The oil sump was peeled back, and the exhaust pipes were crushed. The propeller bolts were pulled from the hub. The following parts were separated from the engine as a result of impact damage; the number 5 rocker cover, intake pipes, prop governor, started, vacuum pump, both magnetos, alternator, tachometer, generator, oil cooler and the fuel control unit. The overall condition and visual examination of the engine a ## Aircraft - Registration: [N7648Q](https://openairdocs.org/deregistered/N7648Q-2002-03-04), registration cancelled 2002-03-04, S/N 310Q0427, built 1971 (OpenAirDocs) - Reported make and model: Cessna 310Q - Registry model: [Cessna 310Q](https://openairdocs.org/model/cessna-310q) (registry code 2074242) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 310Q0427 - Airframe hours: 3650 - Engines: Continental IO-470V 260 horsepower reciprocating; Continental io-470V 260 horsepower reciprocating - Damage: Destroyed - Flight: Business, Part 91 - Operator: Allen W. Watson - Registered owner: Quality Aircraft Sales LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, April 1, 2001, 35 hours before - Departed: INT, Winston Salem, NC - Destination: GHM, Centerville, TN - Flight plan: IFR - Airport: INT, Smith Reynolds Airport, runway 22, 3,738 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: fatal; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, valid medical--no waivers/lim.; last flight review May 4, 2001; seat: left; toxicology performed; flight hours: 2,825 total, 34 in this make and model, 2,275 as pilot in command, 16 in the last 90 days, 5 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 300° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 68 °F, dew point 34 °F - Altimeter: 30.29 inHg - Observed at: INT, 4 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 (OpenAirDocs). - [Accident 20011107030639A](https://openairdocs.org/incident/20011107030639A), Nov 7, 2001: Cessna 310Q, Winston-Salem, NC, No damage, 1 fatal. (-23) On November 7, 2001 at 1118 eastern standard time, a Cessna 310Q, N7648Q, collided with the trees and subsequently the ground in a residential area six… ## Other investigations on N7648Q (1) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB LAX00LA188](https://openairdocs.org/ntsb/LAX00LA188), May 9, 2000: Cessna 310Q (N7648Q), Mesa, AZ, substantial damage. Probable cause: the overload fracture and separation of the right main landing gear attachment. ## Docket (34 files) The files NTSB released with the investigation on April 18, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=53745. 12.7 MB in all. - Toxicological Report (item 1, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459864&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Supplement A - Wreckage Documentation (item 2, .PDF, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180858&FileExtension=.PDF&FileName=Supplement%20A%20-%20Wreckage%20Documentation-Master.PDF - Supplement B - Cockpit Documentation (item 3, .PDF, 261 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180859&FileExtension=.PDF&FileName=Supplement%20B%20-%20Cockpit%20Documentation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 4, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459865&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 5, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459866&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Wreckage Diagram (item 6, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180862&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Air Traffic Control Transcript (item 7, .PDF, 251 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459867&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20Transcript-Master.PDF - Radar Plots (item 8, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180864&FileExtension=.PDF&FileName=Radar%20Plots-Master.PDF - Maintenance Logbooks (item 9, .PDF, 184 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459868&FileExtension=.PDF&FileName=Maintenance%20Logbooks-Master.PDF - Cessna Metallurgy Report (item 10, .PDF, 975 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180866&FileExtension=.PDF&FileName=Cessna%20Metallurgy%20Report-Master.PDF - Photo 1 - First tree contact looking up the flight path (item 11, .PDF, 470 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180877&FileExtension=.PDF&FileName=Photo%201%20-%20First%20tree%20contact%20looking%20up%20the%20flight%20path-Master.PDF - Photo 2 - Vertical stabilizer and lower fuselage skin (item 12, .PDF, 465 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180880&FileExtension=.PDF&FileName=Photo%202%20-%20Vertical%20stabilizer%20and%20lower%20fuselage%20skin-Master.PDF - Photo 3 - Right wing and engine area (item 13, .PDF, 478 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180882&FileExtension=.PDF&FileName=Photo%203%20-%20Right%20wing%20and%20engine%20area-Master.PDF - Photo 4 - Baggage door (item 14, .PDF, 481 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180883&FileExtension=.PDF&FileName=Photo%204%20-%20Baggage%20door-Master.PDF - Photo 5 - Right wing and engine area (item 15, .PDF, 477 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180884&FileExtension=.PDF&FileName=Photo%205%20-%20Right%20wing%20and%20engine%20area-Master.PDF - Photo 6 - Elevator trim screw jack actuator (item 16, .PDF, 411 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180885&FileExtension=.PDF&FileName=Photo%206%20-%20Elevator%20trim%20screw%20jack%20actuator-Master.PDF - Photo 7 - Elevator trim screw jack actuator (item 17, .PDF, 438 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180886&FileExtension=.PDF&FileName=Photo%207%20-%20Elevator%20trim%20screw%20jack%20actuator-Master.PDF - Photo 8 - Rudder trim tab screw jack actuator (item 18, .PDF, 426 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180887&FileExtension=.PDF&FileName=Photo%208%20-%20Rudder%20trim%20tab%20screw%20jack%20actuator-Master.PDF - Photo 9 - Elevator trim screw jack actuator (item 19, .PDF, 356 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180888&FileExtension=.PDF&FileName=Photo%209%20-%20Elevator%20trim%20screw%20jack%20actuator-Master.PDF - Photo 10 - Close-up of forward elevator bellcrank (item 20, .PDF, 404 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180889&FileExtension=.PDF&FileName=Photo%2010%20-%20Close-up%20of%20forward%20elevator%20bellcrank-Master.PDF - Photo 11 - Close-up of elevator trim screw jack actuator (item 21, .PDF, 425 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180890&FileExtension=.PDF&FileName=Photo%2011%20-%20Close-up%20of%20elevator%20trim%20screw%20jack%20actuator-Master.PDF - Photo 12 - Aft elevator bellcrank (item 22, .PDF, 444 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180891&FileExtension=.PDF&FileName=Photo%2012%20-%20Aft%20elevator%20bellcrank-Master.PDF - Photo 13 - Close-up of aft elevator bellcrank (item 23, .PDF, 417 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180892&FileExtension=.PDF&FileName=Photo%2013%20-%20Close-up%20of%20aft%20elevator%20bellcrank-Master.PDF - Photo 14 - Left propeller (item 24, .PDF, 466 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180893&FileExtension=.PDF&FileName=Photo%2014%20-%20Left%20propeller-Master.PDF - Photo 15 - Aft elevator push-pull tube (item 25, .PDF, 473 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180894&FileExtension=.PDF&FileName=Photo%2015%20-%20Aft%20elevator%20push-pull%20tube-Master.PDF - Photo 16 - Right propeller (item 26, .PDF, 459 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180895&FileExtension=.PDF&FileName=Photo%2016%20-%20Right%20propeller-Master.PDF - Photo 17 - Left propeller (item 27, .PDF, 475 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180896&FileExtension=.PDF&FileName=Photo%2017%20-%20Left%20propeller-Master.PDF - Photo 18 - Note tree bark imbedded in right propeller (item 28, .PDF, 428 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180897&FileExtension=.PDF&FileName=Photo%2018%20-%20Note%20tree%20bark%20imbedded%20in%20right%20propeller-Master.PDF - Photo 19 - Power quadrant (item 29, .PDF, 425 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180899&FileExtension=.PDF&FileName=Photo%2019%20-%20Power%20quadrant-Master.PDF - Photo 20 - Close-up of the elevator actuator rod end (item 30, .PDF, 424 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180900&FileExtension=.PDF&FileName=Photo%2020%20-%20Close-up%20of%20the%20elevator%20actuator%20rod%20end-Master.PDF - Photo 21 - Parts sent for examination by NTSB (item 31, .PDF, 419 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180902&FileExtension=.PDF&FileName=Photo%2021%20-%20Parts%20sent%20for%20examination%20by%20NTSB-Master.PDF - Photo 22 - Elevator trim push-pull tube rod end (item 32, .PDF, 407 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180904&FileExtension=.PDF&FileName=Photo%2022%20-%20Elevator%20trim%20push-pull%20tube%20rod%20end-Master.PDF - Photo 23 - Elevator push-pull tube rod end (item 33, .PDF, 392 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180905&FileExtension=.PDF&FileName=Photo%2023%20-%20Elevator%20push-pull%20tube%20rod%20end-Master.PDF - Photo 24 - Close-up of the aileron trim actuator rod end. Note that the cotter-pin is missing. (item 34, .PDF, 405 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180907&FileExtension=.PDF&FileName=Photo%2024%20-%20Close-up%20of%20the%20aileron%20trim%20actuator%20rod%20end.%20%20Note%20that%20the%20cotter-pin%20is%20missing.-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.