CEN09CA078

NTSB accident investigation · Cessna 172S · Waukesha, WI · November 26, 2008

Accident · No injuriesData collectionFinal report
Date
November 26, 2008, 14:30 local (20:30 UTC)
Place
Waukesha, WI
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N833SPCessna 172S
Defining event
Takeoff: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report December 24, 2008
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration - Milwaukee FSDO
FAA report
20081126854859A
Case key
69517

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's failure to maintain aircraft control during takeoff and his failure to ensure that the elevator trim was properly set before takeoff. Contributing to the accident was the pilot's lack of autopilot system knowledge.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Knowledge: knowledge of equipmentPersonnel issues › Experience/knowledge · PilotAll aircraft: 69 casesProbable cause
Flight control system: elevator tab control systemAircraft › Aircraft systems · Incorrect use/operationAll aircraft: 37 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotAll aircraft: 9,295 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported that the autopilot was inadvertently engaged while taxiing to the departure runway. The pilot and his passenger attempted to disengage the autopilot by depressing the "A/P" button on the unit's control panel. The pilot reported that there were warning buzzers sounding as they attempted to disengage the autopilot. The pilot eventually turned off the avionics master switch in order to completely power down the autopilot. After he reestablished power to the avionics, the autopilot appeared to be disengaged. He then contacted the control tower for a takeoff clearance. The airplane "prematurely" rotated and became airborne during the takeoff roll. The pilot stated that he immediately aborted the takeoff, but "struggled with elevator control because of a significant nose up pressure." The airplane landed off the left side of the runway, impacted a snow bank and another runway before coming to rest nose down. A post-accident examination of the airplane showed that the nose landing gear had collapsed, causing substantial damage to the engine firewall. The two-axis autopilot system had servos that controlled the elevator and elevator trim positions. The elevator trim was not in the takeoff position, with the indicator showing a nose-up trim setting of about 8/10 of its total travel. No anomalies were noted during an operational test of the autopilot system or after a download of its fault log. The autopilot was installed with the correct software version and was in compliance with all required airworthiness directives. The pilot reported that he had minimal experience with the use of an autopilot and that he had not received training on the autopilot system installed in the accident airplane.

Factual narrative

The pilot reported that the autopilot was inadvertently engaged while taxiing to the departure runway. The pilot and his passenger attempted to disengage the autopilot by depressing the "A/P" button on the unit's control panel. The pilot reported that there were warning buzzers sounding as they attempted to disengage the autopilot. The pilot eventually turned off the avionics master switch in order to completely power down the autopilot. After he reestablished power to the avionics, the autopilot appeared to be disengaged. He then contacted the control tower for a takeoff clearance. The airplane "prematurely" rotated and became airborne during the takeoff roll. The pilot stated that he immediately aborted the takeoff, but "struggled with elevator control because of a significant nose up pressure." The airplane landed off the left side of the runway, impacted a snow bank and another runway before coming to rest nose down. A post-accident examination of the airplane showed that the nose landing gear had collapsed, causing substantial damage to the engine firewall. The two-axis autopilot system had servos that controlled the elevator and elevator trim positions. The elevator trim was not in the takeoff position, with the indicator showing a nose-up trim setting of about 8/10 of its total travel. No anomalies were noted during an operational test of the autopilot system or after a download of its fault log. The autopilot was installed with the correct software version and was in compliance with all required airworthiness directives. The pilot reported that he had minimal experience with the use of an autopilot and that he had not received training on the autopilot system installed in the accident airplane.

Aircraft

Registration
N833SP
Reported as
Cessna 172S
Category
Airplane
Serial number
172S8724
Airframe hours
4,498.1
Engine
Lycoming IO-360-L2A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Spring City Aviation, Inc.
Registered owner
Spring City Aviation, Inc.
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
100 hour · November 26, 2008
Departed
KUES · Waukesha, WI
Destination
K87Y · Cottage Grove, WI
Airport
KUES · Waukesha County Airport, runway 28, 5,848 × 100 ft, concrete

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
52
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
July 16, 2008
Seat
Left
Flight hours
77 total · 8 in this make and model · 34 as pilot in command · 9 in the last 90 days · 2 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
37 °F, dew point 21 °F
Altimeter
29.96 inHg
Observed at
KUES

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.