CEN22LA202

NTSB accident investigation · Cessna 421C · Monroe, LA · May 15, 2022

Accident · No injuriesClass 3 · LimitedFinal report
Date
May 15, 2022, 13:20 local (18:20 UTC)
Place
Monroe, LA
Injuries
6 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N619ACCessna 421C
Defining event
Initial climb: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Federal Aviation Administration
FAA report
20220515007069A
Case key
105086

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

On this page

Probable cause

The failure of the maintenance personnel to properly reinstall the elevator trim tab hardware, which resulted in an in-flight separation of the elevator.

Findings · 1

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.

Maintenance: installationPersonnel issues › Task performance · Maintenance personnelCessna 421C: 1 caseAll aircraft: 371 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 stated that, immediately after departure, he heard a loud pop and the control yoke oscillated violently. He declared an emergency and diverted to an airport with a longer runway and emergency services. The control yoke and airplane continued to oscillate until the airplane was on final approach, then the oscillation stopped. The pilot landed the airplane without further incident. A postaccident examination of the airplane revealed that the right elevator had mostly separated from the horizontal stabilizer and only a small portion of the inboard elevator remained attached. There was a small puncture on the right side of the rudder, likely from the elevator impacting the rudder when it separated in flight. The elevator trim push-pull tube remained attached to the trim actuator; however, there was no bolt, nut, or cotter pin attached to the aft fork connection, and the trim tab was missing. The push-pull tube did not exhibit any preaccident damage or anomalies. The remainder of right elevator and trim tab were not located. The elevator trim system was re-rigged two days before the accident. The maintenance personnel stated that they did not ensure that the push-pull tube hardware was reinstalled. The load applied between the push pull tube and the trim tab held the bolt in place for 4 flight hours, and it’s likely that every time there was no load on the bolt it was able to move. Once the bolt finally backed out, the trim tab would have been free to move without control. It is likely that the freely moving trim tab resulted in the airplane oscillation and ultimately the in-flight separation of the elevator.

Factual narrative

On May 15, 2022, about 1320 central daylight time, a Cessna 421C, N619AC, was substantially damaged when it was involved in an accident near Monroe, Louisiana. The pilot and five passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that immediately after departure from Morehouse Memorial Airport (BQP), Bastrop, Louisiana, he heard a loud pop and the control yoke oscillated violently. He declared an emergency and diverted to Monroe Regional Airport (MLU), Monroe, Louisiana, about 16 miles southwest, for a longer runway and emergency services. The control yoke and airplane continued to oscillate until the airplane was on final approach, about 3 miles from MLU, then the oscillation stopped. The pilot landed the airplane without further incident. A postaccident examination of the airplane revealed that the right elevator had mostly separated from the horizontal stabilizer and only a small portion of the inboard elevator remained attached. There was a small puncture on the right side of the rudder. The elevator trim push-pull rube remained attached to the trim actuator; however, there was no bolt, nut, or cotter pin attached to the aft fork connection, and the trim tab was missing. The push-pull tube did not exhibit any preaccident damage or anomalies. The remainder of right elevator and trim tab were not located. A review of the airplane’s maintenance logbooks revealed that the elevator trim system was re-rigged on May 13, 2022, two days before the accident. The maintenance personnel who completed the work and signed off on the logbook stated that he did not ensure that the push-pull tube hardware was reinstalled. He added that he checked everything else but missed that step. The airplane had accumulated about 4 hours of flight time since the elevator trim maintenance was completed. As a result of the accident, the maintenance facility updated their company practices to include a secondary inspection sign-off and updated their work order close out procedures.

Aircraft

Registration
N619AC
Reported as
Cessna 421C
Category
Airplane
Serial number
421C0336
Built
1977
Airframe hours
6,878
Engines
Cont Motor GTSI0-520-F-K, 435 horsepower, reciprocatingCont Motor GTSI0-520-F-K, 435 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Raider Aviation
Registered owner
Raider Aviation
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · May 13, 2022 · 4 hours before
Departed
BQP · Bastrop, LA
Destination
MAI · Marianna, FL
Airport
MLU · Monroe Regional Airport, runway 22, 7,504 × 150 ft, asphalt
Equipment
Auto-pilot, ADS-B, Data recorder

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
71
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
30,000 total

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 4 knots
Visibility
10 statute miles
Temperature
90 °F, dew point 70 °F
Altimeter
29.95 inHg
Observed at
KMLU, 7 nm away
METAR
KMLU 151753Z 19004KT 10SM FEW040 FEW048 32/21 A2995 RMK AO2 SLP139 T03170211 10317 20211 56017

Docket · 12

The files NTSB released with the investigation on March 28, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 17.3 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.