# NTSB CEN12IA554: Cessna 560XL, N108EK, Des Moines, IA, August 15, 2012

- Type: NTSB incident investigation
- Classification: Incident · No injuries · Incident investigation · Final report
- Date: August 15, 2012, 08:35 local (13:35 UTC)
- Place: Des Moines, IA
- Coordinates: 41.533889, -93.663055 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=41.5339&lon=-93.6631&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute-cruise: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333)
- Highest injury: No injuries
- Injuries: 8 uninjured
- 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
- NTSB case key (mKey): 84721
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN12IA554
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/84721/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=84721
- Page: https://openairdocs.org/ntsb/CEN12IA554

## 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

NTSB's coded findings; those marked are part of the probable cause.

- [Flight control system: elevator tab control system](https://openairdocs.org/ntsb-findings/01022731): Aircraft › Aircraft systems · Malfunction (probable cause); cases with it: [All aircraft, 37 cases](https://openairdocs.org/ntsb-findings/01022731/cases.md)
- [Auto flight system: autopilot system](https://openairdocs.org/ntsb-findings/01022210): Aircraft › Aircraft systems · Malfunction (probable cause); cases with it: [All aircraft, 28 cases](https://openairdocs.org/ntsb-findings/01022210/cases.md)
- [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute-cruise: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) (defining event); cases with it: [All aircraft, 410 cases](https://openairdocs.org/ntsb-events/333/sequence.md)
- [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Uncontrolled descent: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md)
- [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md)

## 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 (not matched to a registry record)
- Reported make and model: CESSNA 560XL
- Category: Airplane
- Serial number: 560-5032
- Airframe hours: 4510
- Engines: P&W CANADA PW545A 3372 lbs thrust turbo fan; P&W CANADA PW545A 3372 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

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 42; injuries: none; 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
- Co-pilot; age 58; injuries: none; 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

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Incident 20120815020589I](https://openairdocs.org/incident/20120815020589I), Aug 15, 2012: Cessna 560XL, Des Moines, IA, No damage. According to the pilots,the following occurred. The aircraft departed fcn at 0815 on 08/15/2012.the intended destination was arlington,TX.prior to departing…

## Docket (7 files)

The files NTSB released with the investigation on November 24, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=84721. 5.9 MB in all.

- Pilot/Operator Aircraft Accident Report (item 1, .PDF, 855 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419314&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report-Redacted.PDF
- Cockpit Voice Recorder Summary Report (item 2, .PDF, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419315&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%20Summary%20Report%20-Master.PDF
- Operator Summary of Post-Incident Examination (item 3, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419316&FileExtension=.PDF&FileName=Operator%20Summary%20of%20Post-Incident%20Examination-Master.PDF
- Airplane Maintenance Records (item 4, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419317&FileExtension=.PDF&FileName=Airplane%20Maintenance%20Records-Redacted.PDF
- Pilot’s Abbreviated Checklist – Excerpt (item 5, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419318&FileExtension=.PDF&FileName=Pilot%E2%80%99s%20Abbreviated%20Checklist%20%E2%80%93%20Excerpt-Master.PDF
- Cessna Service Bulletin SL560XL-22-02 – Auto Flight Servo Drive (item 6, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419319&FileExtension=.PDF&FileName=Cessna%20Service%20Bulletin%20SL560XL-22-02%20%E2%80%93%20Auto%20Flight%20Servo%20Drive-Master.PDF
- Statement of Party Representative to NTSB Investigation (item 7, .PDF, 237 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419320&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representative%20to%20NTSB%20Investigation-Redacted.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.

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