ERA14LA015

NTSB accident investigation · Piper PA-22-135 · Selinsgrove, PA · October 4, 2013

Accident · Serious injuriesLimited investigationFinal report
Date
October 4, 2013, 14:20 local (18:20 UTC)
Place
Selinsgrove, PA
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N170JHPiper PA-22-135
Defining event
Takeoff: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed · report October 27, 2014
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20131004019599A
Case key
88271

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 incorrect (reverse) rigging of the elevator cables by maintenance personnel and their subsequent failure to verify that the rigging was correct during postmaintenance checks and the pilot's inadequate preflight check.

Findings · 6

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.

Flight control system: elevator control systemAircraft › Aircraft systems · Incorrect service/maintenancePiper PA-22-135: 1 caseAll aircraft: 74 casesProbable cause
Maintenance: replacementPersonnel issues › Task performance · Maintenance personnelPiper PA-22-135: 1 caseAll aircraft: 70 casesProbable cause
Inspection: post maintenance inspectionPersonnel issues › Task performance · Maintenance personnelPiper PA-22-135: 1 caseAll aircraft: 57 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · PilotPiper PA-22-135: 1 caseAll aircraft: 792 casesProbable cause
Flight control system: elevator control systemAircraft › Aircraft systems · Inadequate inspectionPiper PA-22-135: 1 caseAll aircraft: 74 casesProbable cause
Inspection: post maintenance inspectionPersonnel issues › Task performance · PilotPiper PA-22-135: 1 caseAll aircraft: 57 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 reported that, during takeoff, he applied full throttle and that, when the airplane began to gain airspeed, he pushed the yoke forward to bring the tailwheel off the runway. The tail did not rise, and the airplane subsequently "jumped" off the runway; the pilot pushed the yoke forward again, but the airplane continued to climb. The pilot then decreased the engine power, the airplane's nose lowered, and the pilot pulled back on the yoke to arrest the descent, but the nose did not rise. The airplane continued to descend at a higher rate, and the pilot applied nose-up trim; however, the airplane subsequently impacted the runway. Examination of the airplane maintenance logbooks revealed that the accident flight was the first flight after an annual inspection had been completed and that the elevator control cables were replaced during the inspection. Examination revealed that the elevator control cables were installed incorrectly and moved the elevators in the direction opposite to that commanded: when the pilot pushed the yoke forward, the airplane climbed, and, when the pilot pulled the yoke aft, the airplane descended. It is likely that the maintenance personnel installed the flight control cables incorrectly and failed to verify that the routing from the elevator cables to the control yoke was correct during the recent annual inspection and postmaintenance check. It is also likely that the pilot failed to perform an adequate preflight check, which required the pilot to verify that all controls were in the proper position.

Factual narrative

On October 4, 2013, about 1420 eastern daylight time, a Piper PA-22, N170JH, impacted the runway immediately after takeoff from Penn Valley Airport (SEG), Selinsgrove, Pennsylvania. The private pilot and passenger sustained serious injuries. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 and no flight plan had been filed. Visual meteorological conditions prevailed for the personal local flight, which was originating at the time of the accident. According to the pilot, he completed the before takeoff checklist, which included a flight control check of the tailwheel equipped airplane; however, he could not see the elevator from the pilot seat. He taxied the airplane onto the runway, applied full throttle, and when the airplane began to gain airspeed, he pushed the yoke forward in order to bring the tailwheel off the runway. The airplane departed the runway, the pilot pushed the yoke forward again, but the airplane continued to climb at a "low airspeed." The pilot decreased the engine power, the nose of the airplane lowered, and the pilot pulled back on the yoke to arrest the descent. The airplane responded by descending at a higher rate, the pilot applied nose-up trim; however, the airplane impacted the runway. The pilot did not recall any events after the airplane impacted the runway. According to a witness, he saw the airplane taxiing on the parallel taxiway, then enter the runway without stopping, and begin the takeoff roll. Immediately after the main landing gear departed the runway, the airplane "went into a vertical climb." Then, above the runway, the nose of the airplane dropped, and it descended vertically in a slight left turn. The airplane impacted the runway, which resulted in substantial damage to the wings and fuselage. According to the airplane maintenance logbooks, the annual inspection was recorded on August 22, 2013, at a total time of 3425.6 hours. The airframe maintenance records indicated that the left hand and right hand elevator cables were replaced at that time. A postaccident examination of the airplane revealed that the tachometer in the airplane indicated a total time of 3425.9 hours. In an interview with the mechanics that performed the annual maintenance, they stated that during the annual inspection the mechanics decided to replace the elevator cables since they were frayed. The mechanics routed the new cables in with the part tags attached and a second mechanic confirmed the cable installation. Then, they performed a flight control check utilizing the control column to confirm the correct installation of the elevator cables. Once checking the airplane, one of the mechanics noticed that a bolt was too short, removed, one cable, replaced the bolt with a longer bolt, and reattached the elevator cable. When asked if they verified the cable rigging, both mechanics stated that they confirmed the correct routing from the elevator cables to the control yoke. In addition, theystated there was no maintenance manual for the airplane and they used the illustrated parts catalog in order to install the cables. Examination of the airplane by a Federal Aviation Administration inspector revealed that the elevator control cables moved the opposite direction as commanded. When the elevator control cable was operated that corresponded to the yoke being pushed forward, the elevator control surface moved in the upward direction or positioned the airplane in a nose up attitude. When the elevator control cable was operated that corresponded to the yoke being pull aft, the elevator control surface moved downward or positioned the airplane in a nose down attitude. In the operating instructions for the airplane, under the section labeled "Preflight," it stated that "upon entering the plane, the pilot should ascertain that all controls operate normally and are in proper position and that the door is closed and latched." In the "Maintenance" section of the PA-22 Owners' Handbook, it stated in the "Leveling and Rigging" section that "In rigging the control system of the Tri-Pacer, this procedure should be followed: (1) Center the nose wheel, rudder pedals, rudder and ailerons with the interconnecting cables slack at turnbuckles, located behind the baggage compartment. (2) Check the airplane in flight for proper trim with the interconnecting cables slack. (3) During the flight check, if ailerons do not line up with the flap trailing edges equally, adjust the aileron tab to obtain proper aileron position." In addition, the Piper Tri-Pacer Inspection Report, section "D. Fuselage and Empennage Group" task No. 9 of stated to "inspect rudder, elevator and stabilizer trim cables, turnbuckles, guides and pulleys for safety, damage, corrosion and operation."

Aircraft

Registration
N170JH
Reported as
Piper PA-22-135
Category
Airplane
Serial number
22-1645
Built
1953
Airframe hours
3,426
Engine
Lycoming O-290 SERIES, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 22, 2013
Departed
SEG · Selinsgrove, PA
Destination
SEG · Selinsgrove, PA
Airport
SEG · Penn Valley Airport, runway 17, 4,760 × 75 ft, asphalt

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
34
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Seat
Left
Flight hours
9,999 total · 9,999 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 66 °F
Altimeter
30.02 inHg
Observed at
SEG

Docket · 12

The files NTSB released with the investigation on September 16, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.6 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.

Other investigations on N170JH · 1

Matched to the same aircraft by N-number and date.