CEN12IA554

NTSB incident investigation · Cessna 560XL · Des Moines, IA · August 15, 2012

Incident · No injuriesIncident investigationFinal report
Date
August 15, 2012, 08:35 local (13:35 UTC)
Place
Des Moines, IA
Injuries
8 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N108EKCessna 560XL
Defining event
Enroute-cruise: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report February 23, 2015
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA -- Des Moines Flight Standards, Elliott Aviation, Cessna Aircraft Company
FAA report
20120815020589I
Case key
84721

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

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Probable cause

A temporary loss of control during cruise flight for reasons that could not be determined because postincident examination of the autopilot, pitch trim systems, and horizontal stabilizer revealed no anomalies consistent with a loss of control.

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.

Flight control system: elevator tab control systemAircraft › Aircraft systems · MalfunctionAll aircraft: 37 casesProbable cause
Auto flight system: autopilot systemAircraft › Aircraft systems · MalfunctionAll aircraft: 28 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedAll aircraft: 1,269 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 flight crewmembers reported that, after about 10 minutes of cruise flight at 40,000 ft pressure altitude, they observed an autopilot pitch trim mistrim annunciation and an associated master caution indication. As they began to reference the applicable checklist, the autopilot automatically disengaged, the airplane suddenly pitched down, and the airspeed increased to about 30 knots over the redline. The flight crew regained control of the airplane and then leveled it at 33,000 ft pressure altitude. The flight crew subsequently landed the airplane without further incident. The autopilot was not used after the temporary loss of airplane control; however, the electric pitch trim was used after passing through 10,000 ft mean sea level, and it functioned normally. A postincident examination of the autopilot, pitch trim systems, and horizontal stabilizer did not reveal any anomalies consistent with a loss of control.

Factual narrative

On August 15, 2012, about 0835 central daylight time, a Cessna 560XL, N108EK, diverted to Des Moines International Airport (DSM), Des Moines, Iowa, following a loss of control during cruise at Flight Level (FL) 400. The two pilots and six passengers were not injured. The airplane sustained minor damage. The aircraft was registered to New Heights Aviation LLC and operated by Elliott Aviation under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the flight, which was operated on an instrument flight rules flight plan. The flight originated from Flying Cloud Airport (FCM), Eden Prairie, Minnesota, at 0748, with an intended destination of Arlington Municipal Airport (GKY), Arlington, Texas.The flight crew reported that after about 10 minutes of cruise flight at 40,000 feet pressure altitude, they observed an autopilot pitch trim mis-trim (AP Pitch Mis-trim) annunciation and associated master caution. As they began to reference the applicable checklist, the autopilot automatically disengaged and the airplane suddenly pitched down to about 20 degrees. The airspeed increased to about 30 knots over redline. The flight crew recovered and leveled the airplane at 33,000 feet pressure altitude. They subsequently elected to divert to DSM and landed without further incident. The autopilot was not used for the duration of the flight. However, the electric pitch trim was used passing 10,000 feet mean sea level and it functioned normally. The flight crew noted that an "abnormally high amount of water" was observed to be draining from the tailcone during the postflight inspection. The cockpit voice recorder (CVR) was downloaded and a summary of the recording was prepared. The CVR summary revealed that as the airplane was leveling at flight level (FL) 400, the co-pilot noted "it's not keeping up with it." He commented about referencing the checklist and added "R-five." About 30 seconds later, a high-pitched tone was recorded simultaneously with the sound of a "thunk" and rustling sounds. Two additional high pitched tones were recorded. These were followed by a beeping tone consistent with the overspeed warning, which lasted for 40 seconds. The flight crew discussed deploying the speed brake and declared an emergency. The flight crew regained control of the airplane and diverted to DSM. During the descent, the crew discussed that they would not use the autopilot for the duration of the flight. Based on further discussions recorded by the CVR, the pilots executed a full flap approach. They subsequently landed at 0844 without further incident. The required pilot actions related to an AP Pitch Mis-trim annunciation were contained on page R-5 of the Pilots' Abbreviated Checklist – Emergency/Abnormal Procedures. The procedure called for: (1) AP Trim Disc Button – Press and Release (if elevator trim not in motion); Pitch Trim – Adjust (as required); and Autopilot – Engage (as desired). A postincident examination ofthe autopilot, pitch trim systems and two-position horizontal stabilizer system did not reveal any anomalies. The left and right elevator electric trim actuators and the autopilot elevator drive servo were subsequently replaced. The airplane was returned to service without any further difficulties.

Aircraft

Registration
N108EK
Reported as
Cessna 560XL
Category
Airplane
Serial number
560-5032
Airframe hours
4,510
Engines
P&W Canada PW545A, 3,372 lbs thrust, turbo fanP&W Canada PW545A, 3,372 lbs thrust, turbo fan
Damage
Minor damage
Flight
Executive/Corporate · Part 91
Operator
Elliott Aviation Flight Services Inc, doing business as Elliott Aviation
Registered owner
New Heights Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · June 29, 2012 · 595 hours before
Departed
FCM · Minneapolis, MN
Destination
GKY · Arlington, TX
Flight plan
IFR
Airport
DSM · Des Moines International
Equipment
Stall warning system, Electronic primary flight display, Electronic multifunction display, Auto-pilot

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
42
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
July 22, 2012
Seat
Right
Restraint
5-point
Flight hours
7,709 total · 620 in this make and model · 5,328 as pilot in command · 114 in the last 90 days · 58 in the last 30 days · 0 in the last 24 hours
Role
Co-pilot
Age
58
Injuries
None
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
July 22, 2014
Seat
Left
Restraint
5-point
Flight hours
8,605 total · 2,010 in this make and model · 7,025 as pilot in command · 87 in the last 90 days · 52 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 59 °F
Altimeter
29.92 inHg
Observed at
DSM, 20 nm away

Docket · 7

The files NTSB released with the investigation on November 24, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.9 MB in all.

FAA reports on this event · 1

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