# NTSB CEN22LA202: Cessna 421C, N619AC, Monroe, LA, May 15, 2022 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: May 15, 2022, 13:20 local (18:20 UTC) - Place: Monroe, LA - Coordinates: 32.58605, -91.931094 - Nearby events: https://openairdocs.org/map.md?lat=32.5861&lon=-91.9311&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) - Highest injury: No injuries - Injuries: 6 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 105086 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22LA202 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105086/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105086 - Page: https://openairdocs.org/ntsb/CEN22LA202 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 421C, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=2076016), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) (defining event); cases with it: [Cessna 421C, 2 cases](https://openairdocs.org/ntsb-events/333/sequence.md?model=2076016), [All aircraft, 410 cases](https://openairdocs.org/ntsb-events/333/sequence.md) ## 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](https://openairdocs.org/aircraft/N619AC), registered now, S/N 421C0336, built 1977 (OpenAirDocs) - Reported make and model: CESSNA 421C - Registry model: [Cessna 421C](https://openairdocs.org/model/cessna-421c) (registry code 2076016) (OpenAirDocs) - Registry engine: [Continental GTSI0-520-F-K](https://openairdocs.org/engine/continental-gtsi0-520-f-k) (registry code 17031, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 421C0336 - Year built: 1977 - Airframe hours: 6878 - Engines: CONT MOTOR GTSI0-520-F-K 435 horsepower reciprocating; CONT 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 71; injuries: none; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20220515007069A](https://openairdocs.org/incident/20220515007069A), May 15, 2022: Cessna 421C, Monroe, LA, Substantial damage. The aircraft departed kbqp on 05/15/2022 at 1315 CDT. Immediately after takeoff a loud pop was heard and a violent oscillation of the control yoke began. The… ## Docket (12 files) The files NTSB released with the investigation on March 28, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105086. 17.3 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14034541&FileExtension=pdf&FileName=6120%20-%20Pilot-operator%20rep_Redacted-Rel.pdf - Correspondence - operator's representative (item 2, PDF, 1 page, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16817898&FileExtension=pdf&FileName=MOR%20-%20Operators%20Rep-Rel.pdf - NTSB investigation summary (item 3, PDF, 4 pages, 442 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16817098&FileExtension=pdf&FileName=NTSB%20Investigation%20Summary-Rel.pdf - Correspondence - maintenance facility (item 4, PDF, 2 pages, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16817691&FileExtension=pdf&FileName=ROC%20-%20English%20Field%20Aviation-Rel.pdf - Maintenance records - elevator trim (item 5, PDF, 1 page, 10.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16817151&FileExtension=pdf&FileName=MX%20log%20-%20elevator%20trim%205-13-22_Redacted-Rel.pdf - Manufacturer service manual excerpt (item 6, PDF, 35 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16817141&FileExtension=pdf&FileName=421C%20MM%205-30%20Elevator%20Elevator%20Trim%20Tab%20and%20Control%20System-Rel.pdf - Photos (item 7, PDF, 4 pages, 3 photos, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16816070&FileExtension=pdf&FileName=Docket%20Photos-Rel.pdf - FAA ADS-B data (item 8, XLSX, 605 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16817264&FileExtension=xlsx&FileName=20220515_A81030_483883084_ADSB%20(accident%20flight)-Rel.xlsx - Statement of party representatives to NTSB investigation (item 9, PDF, 1 page, 252 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13945865&FileExtension=pdf&FileName=Party%20form%20-%20Textron_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 10, PDF, 1 page, 161 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14037716&FileExtension=pdf&FileName=NTSB%20Wreckage%20release%20(signed)_Redacted-Rel.pdf - Textron multi-engine service bulletin MEB-27-02 (item 11, PDF, 12 pages, 746 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16848045&FileExtension=pdf&FileName=MEB-27-02-Rel.pdf - FAA airworthiness directive AD 2016-17-08 (item 12, PDF, 8 pages, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16847602&FileExtension=pdf&FileName=2016-17-08-Rel.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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.