LAX02LA184

NTSB accident investigation · Cessna 172S · Monterey, CA · June 6, 2002

Accident · No injuriesLimited investigationFinal report
Date
June 6, 2002, 12:05 local (19:05 UTC)
Place
Monterey, CA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N748SPCessna 172S
Weather
Visual (VMC) · Day
Status
Completed · report October 23, 2002
Report
Approved by Office Director
Parties
FAA-SJC-FSDO
FAA report
20020606011439A
Case key
54861

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot was unfamiliar with the airplane's systems and failed to set the elevator trim in accordance with the published checklist.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - on ground/waterTakeoff - roll/run
Preflight planning/preparation - inadequatePilot in commandCause
Lack of familiarity with aircraftPilot in commandCause
Checklist - not complied withPilot in commandCause
Elevator trim - incorrectPilot in commandCause

Analysis

The airplane veered off the runway during takeoff; the nose gear collapsed aft and damaged the firewall and fuselage. While in the run-up area the pilot went through her checklist, and received an altitude alert message and a horn went off. She said she pushed every button she could to turn the alert off, but was unsuccessful. She taxied back to the hangar where her flight instructor popped the circuit breaker for the autopilot, which was giving the alert message. Once it was turned off, she taxied out to takeoff. The pilot began the takeoff roll and attempted to rotate, but the control yoke was not effective. The pilot slammed on the brakes, but the airplane departed the right side of the runway. The airplane had full nose down trim after the accident. The pilot said she did not know that she had to manually recycle the trim after pulling the circuit breaker. Section four of Supplement 15 to the Pilot Operating Handbook (POH) described normal procedures for the use of the autopilot. Paragraph A.2 contained a warning that the manual electric trim and autopilot were inoperative if the circuit breaker was pulled. Paragraph eight instructed the pilot to manually set the trim to the takeoff position. Section four of the POH described normal procedures. The before takeoff checklist instructed the pilot to insure that the elevator trim was set for takeoff.

Factual narrative

On June 6, 2002, about 1205 Pacific daylight time, a Cessna 172S, N748SP, veered off the runway during takeoff from runway 28 left at Monterey, California. Del Monte Aviation was operating the airplane under the provisions of 14 CFR Part 91. The private pilot, the sole occupant, was not injured; the airplane sustained substantial damage. The personal cross-country flight was en route to Columbia, California. Visual meteorological conditions prevailed, and a visual flight rules (VFR) flight plan had been filed.

While in the run-up area the pilot went through her checklist, and received an altitude alert message and a horn went off. She said she pushed every button she could to turn the alert off, but was unsuccessful. She taxied back to the hangar where her flight instructor popped the circuit breaker for the autopilot, which was giving the alert message. Once it was turned off, she taxied out to takeoff.

The pilot began the takeoff roll and attempted to rotate, but the control yoke was not effective. The pilot slammed on the brakes, but the airplane departed the right side of the runway. The nose gear collapsed aft and damaged the firewall and fuselage.

The pilot's flight instructor noted that the airplane had full nose down trim after the accident. The pilot said she did not know that she had to manually recycle the trim after pulling the circuit breaker.

Section four of Supplement 15 to the Pilot Operating Handbook (POH) described normal procedures for the use of the autopilot. Paragraph A.2 contained a warning that the manual electric trim and autopilot were inoperative if the circuit breaker was pulled. Paragraph eight instructed the pilot to manually set the trim to the takeoff position.

Section four of the POH described normal procedures. The before takeoff checklist instructed the pilot to insure that the elevator trim was set for takeoff.

Aircraft

Registration
N748SP
Reported as
Cessna 172S
Category
Airplane
Serial number
172S8682
Airframe hours
461
Engine
Lycoming I0-360, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
The Monterrey Bay Aviation Institute, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · May 24, 2002 · 39 hours before
Departed
MRY · Monterey, CA
Destination
O22 · Columbia, CA
Flight plan
VFR
Airport
MRY · Monterey, runway 280, 7,598 × 150 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
63
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Last flight review
September 16, 2001
Seat
Left
Flight hours
918 total · 21 in this make and model · 918 as pilot in command · 4 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 10 knots
Visibility
8 statute miles
Lowest ceiling
None
Temperature
61 °F, dew point 52 °F
Altimeter
29.93 inHg
Observed at
MRY

Docket · 6

The files NTSB released with the investigation on October 3, 2002, on NTSB’s docket system: statements, records, photos and specialists’ reports. 782 KB 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.