# NTSB ERA17FA148: Piper PA 12, N3280M, Sanford, FL, April 8, 2017 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 8, 2017, 12:56 local (16:56 UTC) - Place: Sanford, FL - Coordinates: 28.77, -81.218887 - Nearby events: https://openairdocs.org/map.md?lat=28.7700&lon=-81.2189&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report May 9, 2018 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Lycoming, FAA/FSDO - NTSB case key (mKey): 94974 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17FA148 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94974/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94974 - Page: https://openairdocs.org/ntsb/ERA17FA148 ## Probable cause The incorrect rigging of the elevator control cables, which resulted in a reversal of elevator control inputs applied by the pilot during the takeoff, an excessive nose-high pitch, and subsequent aerodynamic stall after takeoff. Also causal was the inadequate postmaintenance inspection and the pilot's inadequate preflight inspection and before takeoff check, which failed to detect the misrigging. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Flight control system: elevator control system](https://openairdocs.org/ntsb-findings/01022730): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-12, 3 cases](https://openairdocs.org/ntsb-findings/01022730/cases.md?model=7101202), [All aircraft, 74 cases](https://openairdocs.org/ntsb-findings/01022730/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Other (probable cause); cases with it: [Piper PA-12, 3 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=7101202), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Inspection: post maintenance inspection](https://openairdocs.org/ntsb-findings/02061515): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-12, 1 case](https://openairdocs.org/ntsb-findings/02061515/cases.md?model=7101202), [All aircraft, 57 cases](https://openairdocs.org/ntsb-findings/02061515/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-12, 4 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=7101202), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-12, 2 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=7101202), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Piper PA-12, 4 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=7101202), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Piper PA-12, 2 cases](https://openairdocs.org/ntsb-events/030/sequence.md?model=7101202), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Takeoff: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) (defining event); cases with it: [Piper PA-12, 4 cases](https://openairdocs.org/ntsb-events/333/sequence.md?model=7101202), [All aircraft, 410 cases](https://openairdocs.org/ntsb-events/333/sequence.md) - [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Piper PA-12, 6 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=7101202), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-12, 42 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7101202), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The accident flight was the airplane's first flight after undergoing restoration over the course of 2 years. Although the mechanic who had worked on the airplane with the pilot wanted the pilot to do a high-speed taxi test before flight, the pilot wanted to "hurry up" and test fly the airplane as he had a friend visiting and wanted to take him flying in the airplane. During the takeoff, witnesses observed the airplane pitch up into a nose-high attitude just after liftoff, stall, and descend in a nose-down attitude to ground impact. Examination of the wreckage revealed crush damage to the nose and the leading edges of the wings that was consistent with a nearly vertical nose-down flight path at the time of impact. Further examination of the wreckage revealed that the airplane's elevator control cables were misrigged, such that they were attached to the incorrect (opposite) locations on the upper and lower ends of the elevator control horn, resulting in a reversal of elevator control inputs. If the pilot had checked the elevator for correct motion during the preflight inspection and before takeoff check, he likely would have discovered that it was misrigged, and the accident would have been avoided. ## Factual narrative During preflight inspection of a PA-12 (before engine start), a pilot can see the elevator's corresponding movements when the control stick is manipulated (either when standing by the open cockpit door or when seated in the front seat); likewise, a pilot standing on the ground and manipulating the elevator by hand can look forward and see the corresponding control stick movement. During a before takeoff check of the PA-12, a pilot can view the elevator from the pilot seat by turning around and looking back. The National Transportation Safety Board (NTSB) issued Safety Alerts SA-041, "Pilots: Perform Advanced Preflight after Maintenance," and SA-042, "Mechanics: Prevent Misrigging Mistakes," in March 2015. That same month, the NTSB also released a Video Safety Alert, "Airplane Misrigging: Lessons Learned from a Close Call." The NTSB Safety Alerts and video, which inform general aviation pilots and mechanics about the circumstances of these types of accidents and provide information to help prevent such accidents, can be accessed from the NTSB's web site at www.ntsb.gov. The three-seat, high-wing, tail-wheel-equipped, fabric-covered airplane, serial number 12-2136, was manufactured in 1947. It was powered by a 115-horsepower Lycoming O-235-C1C engine, and equipped with a two-bladed, fixed pitch Sensenich propeller. Its most recent annual inspection was completed on March 25, 2017, at which time the airplane had 1,735.57 total flight hours. On April 8, 2017, about 1256 eastern daylight time, a Piper PA-12, N3280M, was destroyed by impact and postcrash fire after takeoff from Orlando Sanford International Airport (SFB), Orlando, Florida. The airline transport pilot was fatally injured. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the local personal flight. According to air traffic control audio information, the pilot received a takeoff clearance for runway 27L for closed traffic, which the pilot acknowledged. There were no further communications with the pilot. Multiple witnesses stated that the airplane accelerated normally, lifted off, and immediately pitched up to a near vertical attitude. One witness stated, "it was like someone took the control yoke full aft." The witnesses reported that the airplane reached an altitude of about 100 ft, stalled, rolled to the right, and descended in a nose-down attitude to impact on the right side of runway 27L. A postimpact fire ensued that was extinguished by aircraft rescue and firefighting personnel on the airport. A witness recorded the flight on his mobile telephone. The video showed the airplane's takeoff roll, rotation, and initial climb and ended as the airplane pitched up to a nose-high attitude. A mechanic who worked on the airplane with the pilot reported that the accident flight was the first flight following a 2-year restoration thatincluded replacement of the wing and fuselage fabric, flight control cables, and electrical wiring. The mechanic stated that he was hesitant for the pilot to fly the airplane on the day of the accident. He wanted the pilot to do a high-speed taxi test first to check the tension on the cables and trim. The pilot stated he wanted to "hurry up and test fly it" as he had a friend visiting and wanted to take him flying in the airplane. The Office of the Medical Examiner, Leesburg, Florida, performed an autopsy of the pilot. The cause of death was listed as thermal and blunt force injuries. The FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing. The results were negative for alcohol and drugs. At 1253, the recorded weather at SFB included wind calm, visibility 10 statute miles, sky clear, temperature 22°C, dew point -3°C, and altimeter 30.11 inches of mercury. The pilot held an airline transport pilot certificate with airplane single- and multi-engine land ratings. He also held a flight instructor certificate with ratings for airplane single-engine, airplane multi-engine, and instrument airplane. His most recent Federal Aviation Administration (FAA) first-class airman medical certificate was issued on February 7, 2017, with the limitation, "must wear corrective lenses. " On the application form for this medical certificate, the pilot reported 25,000 total hours of flight experience and 400 hours in the previous 6 months. According to the pilot's logbooks, he had about 150 total flight hours in the accident airplane. The airplane came to rest inverted on a heading of about 170° magnetic in a grass area about 9 ft north of the north side of runway 27L, adjacent to the 1,000-ft markers. The nose of the airplane was crushed aft. The propeller remained attached to the engine, and it was located adjacent to a linear ground crater consistent with the dimensions of the propeller. The empennage, fuselage, cockpit, and wings were consumed by postimpact fire. The engine exhibited significant thermal damage, and several of its accessories had separated during the impact sequence. The engine crankshaft was manually rotated, and continuity of the valve train was established from the crankshaft flange to the rear accessory section. Thumb compression was obtained on all four cylinders. All flight control surfaces (ailerons, flaps, rudder, elevators, and trimmable horizontal stabilizer) remained attached to their respective attach points. The left and right aileron cables were continuous from the control stick to their respective bellcranks. The rudder cables were continuous from the foot pedals to the rudder bellcrank. The elevator control cables were continuous from the upper and lower attach points on the elevator control horn to the forward and rear control sticks. Manipulation of the elevator control cables revealed that a nose-up input on either control stick resulted in a nose-down deflection of theelevator (instead of the proper nose-up deflection) and vice versa. Further examination revealed that the elevator cables were attached to the incorrect (opposite) attach points on the elevator control horn, which resulted in the reversal of elevator control inputs. ## Aircraft - Registration: [N3280M](https://openairdocs.org/deregistered/N3280M-2017-11-01), registration cancelled 2017-11-01, S/N 12-2136, built 1947 (OpenAirDocs) - Reported make and model: PIPER PA 12 (NO SERIES) - Registry model: [Piper PA-12](https://openairdocs.org/model/piper-pa-12) (registry code 7101202) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 12-2136 - Year built: 1947 - Airframe hours: 1735.57 - Engines: LYCOMING O-235 SERIES 115 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, March 25, 2017 - Departed: SFB, Sanford, FL - Destination: SFB, Sanford, FL - Airport: SFB, Orlando Sanford Intl, runway 27L, 6,647 × 75 ft, asphalt - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; injuries: fatal; flight instructor, airline transport, commercial, private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; seat: front; toxicology performed; flight hours: 25,000 total, 150 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 27 °F - Altimeter: 30.11 inHg - Observed at: SFB, 1 nm away ## 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 20170408003589A](https://openairdocs.org/incident/20170408003589A), Apr 8, 2017: Piper PA-12, Sanford, FL, Destroyed, 1 fatal. On April 8, 2017, about 1256 eastern daylight time, a Piper PA-12, N3280M, was destroyed by impact and a postcrash fire after takeoff from orlando Sanford… ## Docket (9 files) The files NTSB released with the investigation on April 25, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94974. 35.6 MB in all. - Witness Statements (item 1, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462020&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Wreckage Diagrams (item 2, .PDF, 509 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462021&FileExtension=.PDF&FileName=Wreckage%20Diagrams-Master.PDF - Witness Video (item 3, MP4, 20.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462505&FileExtension=mp4&FileName=Witness%20Video-Master - Photo Array (item 4, .PDF, 4 photos, 826 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462506&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Maintenance Records (item 5, .PDF, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462507&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF - Pilot Logbooks (item 6, .PDF, 7.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462508&FileExtension=.PDF&FileName=Pilot%20Logbooks-Master.PDF - Toxicological Report (item 7, .PDF, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462509&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462510&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 9, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462511&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.