- 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.
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.