# NTSB LAX02LA184: Cessna 172S, N748SP, Monterey, CA, June 6, 2002 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 6, 2002, 12:05 local (19:05 UTC) - Place: Monterey, CA - Coordinates: 36.600303, -121.879875 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.6003&lon=-121.8799&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report October 23, 2002 - Report: Approved by Office Director - Parties: FAA-SJC-FSDO - NTSB case key (mKey): 54861 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX02LA184 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54861/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54861 - Page: https://openairdocs.org/ntsb/LAX02LA184 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - on ground/water, takeoff - roll/run - preflight planning/preparation - inadequate, pilot in command (cause) - lack of familiarity with aircraft, pilot in command (cause) - checklist - not complied with, pilot in command (cause) - elevator trim - incorrect, pilot in command (cause) ## 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](https://openairdocs.org/aircraft/N748SP), registered now, S/N 172S8682, built 2000 (OpenAirDocs) - Reported make and model: Cessna 172S - Registry model: [Cessna 172S](https://openairdocs.org/model/cessna-172s) (registry code 2072439) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 172S8682 - Airframe hours: 461 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: none; 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 ## 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 20020606011439A](https://openairdocs.org/incident/20020606011439A), Jun 6, 2002: Cessna 172S, Monterey, CA, No damage. (-23) On June 6, 2002, aircraft N748SP was attempting a take off from the Monterey Peninsula Airport (mry) when the take off was aborted and the pilot lost… ## Docket (6 files) The files NTSB released with the investigation on October 3, 2002, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54861. 782 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - Operator (item 1, .PDF, 341 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40403961&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20Operator-Redacted.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - Pilot (item 2, .PDF, 150 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40403962&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20Pilot-Redacted.PDF - Miscellaneous-Pilot statement (item 3, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40161665&FileExtension=.PDF&FileName=Miscellaneous-Pilot%20statement-Master.PDF - Miscellaneous-Record of Conversation (item 4, .PDF, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40403963&FileExtension=.PDF&FileName=Miscellaneous-Record%20of%20Conversation-Redacted.PDF - Miscellaneous-Pilot Operators Handbook, Autopilot Supplement (item 5, .PDF, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40161667&FileExtension=.PDF&FileName=Miscellaneous-Pilot%20Operators%20Handbook,%20Autopilot%20Supplement-Master.PDF - Miscellaneous-Take-Off Checklist (item 6, .PDF, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40161668&FileExtension=.PDF&FileName=Miscellaneous-Take-Off%20Checklist-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.