# NTSB ERA09LA230: Champion 7HC, N8560E, Centre, AL, April 4, 2009 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: April 4, 2009, 12:47 local (17:47 UTC) - Place: Centre, AL - Coordinates: 34.165, -85.635002 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.1650&lon=-85.6350&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 22, 2010 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Cessna, Birmingham FSDO - NTSB case key (mKey): 73597 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09LA230 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73597/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73597 - Page: https://openairdocs.org/ntsb/ERA09LA230 ## Probable cause The pilot's inability to maintain aircraft control during climb due to an improperly installed rudder pedal control tube. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Flight control system: rudder control system](https://openairdocs.org/ntsb-findings/01022720): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Champion 7HC, 1 case](https://openairdocs.org/ntsb-findings/01022720/cases.md?model=21101PN), [All aircraft, 93 cases](https://openairdocs.org/ntsb-findings/01022720/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Champion 7HC, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=21101PN), [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. - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Champion 7HC, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=21101PN), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Champion 7HC, 3 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=21101PN), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis Witnesses reported that during takeoff the airplane climbed to approximately 20 to 50 feet, rolled to the left into a steep bank angle, and then descended and collided with powerlines and a house. Examination of the airplane by an FAA inspector revealed that the right rudder pedal control tube was missing the rod attachment bolt, retainer nut, and cotter pin. According to the airplane manufacturer the push pull tube system discovered during the examination was not installed at the factory and no record of the install was located in the airframe logbooks. Examination of the engine, additional flight control system components, and the aircraft structure revealed no evidence of preimpact mechanical failure or malfunction. ## Factual narrative On April 4, 2009, at about 1247 central daylight time, a Champion 7HC, N8560E collided into a private home near the Centre Municipal Airport, Centre, Alabama. The private pilot was killed, and the airplane was substantially damaged by post-crash fire. The personal flight was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 91, and no flight plan was filed. Visual meteorological conditions prevailed at the time of the accident. The flight was originating at the time of the accident. According to witnesses, the airplane was departing from the runway, climbed to approximately 20 to 50 feet, and made a hard left bank. The airplane then struck power lines, trees, and crashed into a house. The airplane erupted in flames and the pilot was observed lying outside of the airplane. The pilot, age 52, held a private pilot certificate with ratings for airplane single engine land and sea. His certificate was issued on July 2, 2003. The pilot's last medical examination was on July 4, 2007, for a third-class medical certificate with limitations for corrective lenses. The pilot reported 2,150 flight hours on his last medical application. The two seat, high-wing, fixed gear airplane that was manufactured in 1959. It was powered by a Lycoming O-290 140-hp engine and equipped with a two-bladed Sensenich propeller. Review of the aircraft logbook pages revealed that the last annual inspection was conducted on December 19, 2008, at a total time of 2,013.95 hours. Examination of the wreckage by an Federal Aviation Administration (FAA) inspector revealed that the airplane travel approximately 1,000 feet down the runway before becoming airborne and colliding with the house adjacent the runway. The fabric that covered the airframe was consumed by fire. The remainder of the fuselage was melted, and exhibited impact damage. Examination of the flight control system revealed that the airplane was equipped with a push pull tube rudder control system. The right rudder pedal control tube was missing the rod attachment bolt, retainer nut, and cotter pin. The examination of the engine and system components by the FAA inspector revealed no evidence of a preimpact mechanical malfunction. Review of the logbooks did not reveal any maintenance of the rudder control system. In a telephone conversation with the airplane manufacturer, American Champion, they stated that this model airplane did not come from the factory with a push pull tube rudder system. The system installed in the airplane was a cable type system, and that operators sometimes change this. Review of the logbooks did not reveal this alteration. An autopsy was performed on the private pilot on April 7, 2009, by the Alabama Department of Forensic Sciences, Huntsville, Alabama, as authorized by the coroner of Cherokee County; the cause of death was reported as “94% total body surface burns". Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences ResearchLaboratory, Oklahoma City, Oklahoma. The toxicology report stated no ethanol was detected in vitreous, and no cyanide was detected in blood. Diphenhydramine was detected in the liver; 0.05 (ug/ml, ug/g) of diphenhydramine was detected in blood; 34 (ng/mL, ng/g) of fentanyl was detected in the liver; 12 (ng/mL, ng/g) of fentanyl was detected in blood; 0.94 (ug/mL, ug/g) of lorazepam was detected in the liver; 0.175 (ug/mL, ug/g) of lorazepam was detected in blood; 0.223 (ug/mL, ug/g) of midazolam was detected in the liver; 0.011 (ug/mL, ug/g) of midazolam was detected in blood; 0.385 (ug/ml, ug/g) of morphine was detected in the kidney; and 0.02 (ug/ml, ug/g) of morphine was detected in blood. According to the Chief Investigator of Cherokee County, Alabama, the medications found in the FAA toxicology report were administered in a clinical setting and are consistent with the injuries described in the autopsy report. ## Aircraft - Registration: [N8560E](https://openairdocs.org/deregistered/N8560E-2015-04-30), registration cancelled 2015-04-30, S/N 7HC-9, built 1959 (OpenAirDocs) - Reported make and model: CHAMPION 7HC - Registry model: [Champion 7HC](https://openairdocs.org/model/champion-7hc) (registry code 21101PN) (OpenAirDocs) - Registry engine: [Lycoming 0-290 series](https://openairdocs.org/engine/lycoming-0-290-series) (registry code 41506, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 7HC-9 - Airframe hours: 2013 - Engines: LYCOMING 0-290 SERIES 140 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 19, 2008 - Departed: C22, Centre, AL - Destination: PYP, Centre, AL - Airport: C22, Centre Municipal Airport, runway 09, 3,401 × 80 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: fatal; private; airplane ratings: single-engine land, single-engine sea; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: front; toxicology performed; flight hours: 2,150 total ## Weather - Conditions: Visual (VMC), Day - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 66 °F, dew point 48 °F - Altimeter: 30.02 inHg - Observed at: GAD ## 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 20090404007949A](https://openairdocs.org/incident/20090404007949A), Apr 4, 2009: Bbavia 7HC, Centre, AL, Destroyed, 1 fatal. (-23) Pilot departed rwy 09 at Centre, Alabama (C22). Uncommanded left turn immediately upon departure leading to impact with power lines, pine tree, and… ## Docket (12 files) The files NTSB released with the investigation on November 5, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73597. 7.0 MB in all. - Photo 1-FAA digital- main wreckage (item 1, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315717&FileExtension=.PDF&FileName=Photo%201-FAA%20digital-%20main%20wreckage-Master.PDF - Photo 2-FAA digital- main wreckage (item 2, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315719&FileExtension=.PDF&FileName=Photo%202-FAA%20digital-%20main%20wreckage-Master.PDF - Photo 3-FAA digital- main wreckage (item 3, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315720&FileExtension=.PDF&FileName=Photo%203-FAA%20digital-%20main%20wreckage-Master.PDF - Photo 4-FAA digital-Rudder pedal rudder tube connection point (item 4, .PDF, 626 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315727&FileExtension=.PDF&FileName=Photo%204-FAA%20digital-Rudder%20pedal%20rudder%20tube%20connection%20point-Master.PDF - Photo 5-FAA digital-Rudder tube bolt and castle nut hole (item 5, .PDF, 424 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315728&FileExtension=.PDF&FileName=Photo%205-FAA%20digital-Rudder%20tube%20bolt%20and%20castle%20nut%20hole-Master.PDF - Photo 6-FAA digital-Disconnected rudder tube (item 6, .PDF, 806 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315729&FileExtension=.PDF&FileName=Photo%206-FAA%20digital-Disconnected%20rudder%20tube-Master.PDF - Reports from Federal Agencies-FAA inspector statement (item 7, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315730&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies-FAA%20inspector%20statement-Redacted.PDF - Toxicological Report (item 8, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316936&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Witness Statement (item 9, .PDF, 500 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320549&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF - Other Pertinent Forms and Reports-Logbook page (item 10, .PDF, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320550&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-Logbook%20page-Redacted.PDF - Other Pertinent Forms and Reports-American Champion tech support statement (item 11, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322532&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-American%20Champion%20tech%20support%20statement-Master.PDF - Other Pertinent Forms and Reports-Control system rudder (item 12, .PDF, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322534&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-Control%20system%20rudder-Master.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.