# NTSB ATL04LA126: Piper PA 32R-301, N8451E, Baxley, GA, June 14, 2004 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: June 13, 2004, 22:45 local (Jun 14, 2004, 02:45 UTC) - Place: Baxley, GA - Coordinates: 31.713611, -82.393608 - Nearby events: https://openairdocs.org/map.md?lat=31.7136&lon=-82.3936&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report January 31, 2006 - Report: Approved by Office Director - Parties: Atlanta FSDO - NTSB case key (mKey): 59443 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL04LA126 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/59443/pdf - Page: https://openairdocs.org/ntsb/ATL04LA126 ## Probable cause The mechanical malfunction of the autopilot pitch servo, and the pilot's inability to maintain adequate control pressure to manually retrim the pitch attitude. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, approach - autopilot/flight director,servo - failure (cause) - Loss of control - in flight, approach - emergency procedure - not successful, pilot in command - physical strength overload, pilot in command (cause) - In flight collision with object, approach - object - tree(s) ## Analysis While flying at 2300 feet, the pilot shut off the autopilot and immediately could not maintain pitch control and the airplane went into a series of uncontrollable gyrations. The pilot attempted to regain control of the airplane but was unsuccessful. The airplane collided with trees five miles west of Baxley Municipal Airport. During the post accident functional examination of the autopilot assembly disclosed that when the unit was engaged the pitch servo would only correct the pitch attitude in one direction. Internal examination of the pitch servo revealed that three transistors had been replaced and one transistor appeared original to the unit. Additionally, the functional check of the pitch trim servo solenoid revealed that the unit was not within the design specifications. According to the pilot operating handbook, if the autopilot is disengaged when opposing mistrim forces are encountered, the pilot may be required to exert control forces in excess of 50 pounds to maintain airplane attitude. The pilot will have to maintain this control force while he manually retrim the airplane. ## Factual narrative On June 13, 2004, at 2245 eastern daylight time, a Piper PA-32R-301, N8451E registered to and operated by the private pilot collided with trees while on approach to Baxley Municipal Airport, Baxley, Georgia. The personal flight operated under the provisions of Title 14 CFR Part 91. Visual meteorological conditions prevailed and an instrument flight plan was filed. The airplane was substantially damaged. The pilot was seriously injured. The flight originated from Fulton County Airport, Wauseon, Ohio on June 13, 2004 at 1800 central daylight time. While enroute at 2300 feet, the pilot checked the weather at Baxley Municipal Airport, and with the airport in sight, the pilot decided to cancel his instrument flight plan. The pilot shut off the autopilot and immediately afterward, the pilot discovered that he could not maintain pitch control. As the airplane went into a series of uncontrollable gyrations, the pilot attempted to disable the electric pitch trim but was limited because of the physical force needed on the yoke. The pilot's attempts to regain control of the airplane were unsuccessful. The airplane descended and collided with trees five miles west of Baxley Municipal Airport. Examination of the airplane at the accident site revealed the left wing was severed approximately three feet outboard of fuselage, and the right stabilator assembly was deflected aft 90 -degrees severed at the right side of the airframe. The functional examination of the autopilot components revealed the pitch servo was only correcting itself in one direction; as viewed at the capstan, the unit would run clockwise but not counter-clockwise. Internal examination of the unit revealed three transistors had been replaced and one transistor appeared to have been original to the unit. The transistor that appeared original to the unit is for the clockwise motion; the motor in the unit also appeared to have been original. The functional examination also disclosed that trim springs were out of design specifications, but the clockwise speed was within specifications and the tachometer output was out of design specifications. External examination of the tachometer revealed that it had been previously repaired and a lacquer or glue compound had been applied. The servo solenoid specifications are 21.87 lbs; the solenoid was observed to hold in the counter-clockwise direction, but would allow popping off at 15 to 18 lbs in the clockwise direction. Also, the servo mount, from the pitch servo unit, specifications are 50 lbs plus or minus 5 lbs. The unit was observed to be set at 67 lbs for clockwise direction and 65 lbs for counter-clockwise direction. According to a caution note in the emergency procedures of the pilot operating handbook, "when disconnecting the autopilot after a trim malfunction, hold the control wheel firmly (up to 45 pounds of force on the control wheel may be necessary to hold the aircraft level)." Additionally, "if the autopilot is disengaged under these conditions ( opposing mistrim forces) the pilot may be required to exert control forces in excess of 50 pounds to maintain airplane attitude. The pilot will have to maintain this control force while he manually retrim the airplane. " ## Aircraft - Registration: [N8451E](https://openairdocs.org/deregistered/N8451E-2004-11-05), registration cancelled 2004-11-05, S/N 32R-8113122, built 1981 (OpenAirDocs) - Reported make and model: Piper PA 32R-301 - Registry model: [Piper PA-32R-301](https://openairdocs.org/model/piper-pa-32r-301) (registry code 7103218) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 32R-8113122 - Airframe hours: 2666 - Engines: Lycoming IO-540 SER 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Richard Helminiak - Registered owner: Richard Helminiak - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 4, 2004, 4 hours before - Departed: KUSE, Wauseon, OH - Destination: KBHC, Baxley, GA - Flight plan: IFR - Airport: KBHC, Baxley Municipal Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; injuries: serious; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; last flight review February 3, 2003; seat: left; flight hours: 957 total, 315 in this make and model, 43 in the last 90 days, 11 in the last 30 days ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 0° at 0 knots - Visibility: 7 statute miles - Temperature: 73 °F, dew point 72 °F - Altimeter: 30.10 inHg - Observed at: KAYS, 27 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 20040613030609A](https://openairdocs.org/incident/20040613030609A), Jun 13, 2004: Piper PA32R301, Baxley, GA, Substantial damage. (-23) Pilot filed IFR flight plan from kuse to kbhc at 10,000'. Approximately 4.5 hours after departure while in the descent to Baxley (kbhc) the pilot claims… ## Other investigations on N8451E (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 CHI99LA219](https://openairdocs.org/ntsb/CHI99LA219), Jul 8, 1999: Piper PA-32R (N8451E), Fargo, ND, substantial damage. Probable cause: fuel starvation due to the pilot's fuel mismanagement and the pilot's misjudgment of the landing flare. 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.