- Date
- March 6, 2008, 16:30 local (21:30 UTC)
- Place
- West Chester, PA
- Injuries
- 1 uninjured
- Damage
- Substantial damage
- Phase of flight
- Takeoff
- Aircraft
- N4623WRockwell 112TCA
- Defining event
- Takeoff-rejected takeoff: Runway excursion
- Weather
- Visual (VMC) · Day
- Status
- Completed · report June 11, 2009
- Report
- Approved by Office Director
- Parties
- FAA/FSDO
- FAA report
- 20080306013179A
- Case key
- 67629
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 pilot's failure to ensure that the pitch trim was properly set for takeoff.
Findings · 2
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.
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 accident airplane had just undergone avionics maintenance and was released to the pilot/owner about 30 minutes prior to the accident. According to the technician who conducted the maintenance, the autopilot system operated correctly, and he instructed the pilot to "check his trim before he left, as it runs during ground checks." Prior to engine start, the pilot noticed that the pitch trim was set to the full airplane nose down (AND) position. He reset the trim to the takeoff position, and ensured that the autopilot was off. The pilot reported that during the takeoff roll, the airplane did "not feel right," and he rejected the takeoff. The airplane overran the 3,347 foot-long, dry, asphalt runway, traveled down an embankment, and came to rest in a shallow ditch. Post-accident examination and testing of the airplane elevator and pitch trim system by an FAA inspector confirmed elevator and manual pitch trim control continuity, and the controls were observed to be functional and directionally correct. The electric pitch trim and cockpit pitch trim indicator were also observed to be functional and directionally correct. One witness reported that about 10 minutes elapsed from the time that the airplane was pulled from the maintenance hangar to when the pilot reported the accident.
Factual narrative
History of flight
On March 6, 2008, about 1630 eastern standard time, a Rockwell International 112TCA, N4623W, was substantially damaged when it overran runway 27 during an aborted takeoff from Brandywine Airport (OQN), West Chester, Pennsylvania. The pilot/owner, the sole person on board, was not injured. The flight was being operated under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident, and no flight plan was filed.
According to the pilot, on the morning of the day of the accident, he flew the airplane to OQN for maintenance on the airplane's weather data-link avionics. The pilot also requested that the maintenance facility address a residual autopilot issue from an August 2007 avionics upgrade by the same facility. The pilot stated that the airplane was released to him about 1600 on the day of the accident.
According to maintenance records and a technician's written statement, the autopilot electrical connector for glideslope coupling had been incorrectly "paralleled at the altitude transducer." The technician rewired the assembly to match the avionics manufacturer's cable assembly drawing. He conducted several functional checks, and confirmed that the system was wired and operated correctly. Subsequent to these checks, the technician instructed the pilot to "check his trim before he left as it runs during ground checks."
According to the pilot, prior to engine start, he noticed that the pitch trim was near its full airplane nose down (AND) position. He manually adjusted the trim to the takeoff setting. The pilot estimated that the airplane had a total of 37 gallons of fuel on board, and that the wind was "light and variable" at the time of the attempted takeoff. He conducted a normal engine start, and taxied to the runway. He reported that the engine runup was normal.
The pilot stated that he ensured that the autopilot was off, and that the "trim master breaker" switch was on, which was the manufacturer's recommended configuration for takeoff. The trailing edge flaps were in the retracted position, which was the recommended takeoff setting. The pilot initiated a full-length takeoff by advancing the throttle, and then releasing the brakes once he observed an indication of 30 inches on the manifold pressure (MP) gauge. At an indicated airspeed of approximately 65 knots and with approximately 40 inches MP, the pilot exerted aft pressure on the control column to lift off, but the airplane did "not feel right." The pilot reported that by the time the airspeed was approximately 75 knots, he had moved the column significantly aft, but the pitch attitude only increased slightly, and the airplane did not become airborne. The pilot then rejected the takeoff by retarding the throttle and applying the brakes. The airplane overran the runway at a speed that the pilot estimated to be between 20 and 30 knots. The airplane traveled down an embankment, and came to rest approximately 150 feet from the runway end, in a shallow ditch adjacent to a road. The pilot was uninjured, and there was no fire.
A witness stated that he pulled the accident airplane out of the maintenance hangar about 1630, and that the pilot returned on foot to the maintenance facility to report the accident about 1640.
Personnel information
The pilot held a private pilot certificate with airplane single-engine land rating, and he had approximately 130 total hours of flight experience. He had approximately 85 total hours experience in the accident airplane. Federal Aviation Administration (FAA) records indicate that the airplane was first registered to the pilot in September 2006. His most recent third-class FAA medical certificate was issued in August, 2007.
Aircraft information
The airplane was manufactured in 1977. According to the maintenance records, at the time of the accident, the airplane had accumulated a total time in service of approximately 2,052 hours. The most recent annual inspection was accomplished in May 2006, and the airplane had accumulated approximately 39 hours since the annual inspection. The airplane was equipped with a Century III two-axis (pitch and roll) autopilot. The most recent maintenance activity was accomplished on the day of the accident.
Meteorological information
The 1654 weather observation at an airport located approximately 14 miles north of the accident airport recorded winds from 270 degrees at 4 knots, clear skies, temperature 10 degrees C, dew point minus 2 degrees C, and altimeter setting of 30.18 inches of mercury.
Airport information
According to FAA information, the asphalt runway measured 3,347 feet by 50 feet. Photographs indicate that the departure end of runway 27 terminated in a down-sloping embankment approximately 30 feet high, with a slope of approximately 45 degrees. The pilot reported that the runway surface was dry at the time of the event.
Wreckage and impact information
Inspectors from the FAA arrived on scene approximately 2 hours after the accident. They reported that the propeller, engine cowling, left wing, and nose and left main landing gear incurred impact damage. The inspectors also reported that the pitch trim cockpit indicator and elevator trim tab were both in their respective full AND positions. A tire skid mark began at the painted runway number and continued to the end the pavement, a distance of approximately 375 feet. The next ground scars were three furrows in the grassy overrun beyond the end of the embankment. The furrows were located approximately 100 feet beyond the runway end, and the lateral spacing of the furrows was consistent with the lateral spacing of the accident airplane's landing gear.
Additional information
Manufacturer's Normal Procedures Checklist
A binder containing the manufacturer's "Normal Procedures Checklist" for preflight and takeoff was recovered from the accident airplane. The registration number of the airplane was written on the cover of the binder. The checklist contained two separate entries to turn the master switch on, but it did not contain any corresponding entry between the two "on" entries to turn it off.
The same checklist contained three separate entries concerning the elevator trim setting. Item 9 in the "INTERIOR" section of the "PRE-FLIGHT INSPECTION" portion was "Elevator Trim Tab - NEUTRAL." Item 17 in the "EXTERIOR" section of the "PRE-FLIGHT INSPECTION" portion was "Elevator Trim Tab -CHECK." Item 5 in the "BEFORE TAKEOFF" section was "Elevator Trim Tab - TAKEOFF RANGE."
There were no explicit references to the autopilot in the checklist, but it did contain two implicit references. Item 4 in the "BEFORE STARTING ENGINE" checklist was "Avionics Master Switch - OFF," and item 14 in the "BEFORE TAKEOFF" checklist was "Instruments and Radios - SET."
Laminated Checklist
A double-sided laminated checklist was recovered from the accident airplane, but it did not contain any annotations concerning its applicability to any aircraft type, model, or registration number. This checklist was similar to the manufacturer's checklist described previously. There were no explicit checklist references to the autopilot, but like the manufacturer's checklist, it contained two implicit references. Item 4 in the "BEFORE STARTING ENGINE" checklist was "Avionics Master Switch - OFF," and item 14 in the "BEFORE TAKEOFF" checklist was "Instruments and Radios - SET."
The only entry in the checklist that concerned elevator trim was item 5 in the "BEFORE TAKEOFF" section, which stated "Elevator Trim Tab - TAKEOFF RANGE."
Pilot's Operating Handbook for Autopilot
The manufacturer of the autopilot, Century Flight Systems, developed and provided a 36-page Pilot's Operating Handbook (POH) for the autopilot model that was installed in the accident airplane. The POH contained a "Pilot's Preflight Procedure," which consisted of 13 detaile
Aircraft
- Registration
- N4623W
- Reported as
- Rockwell 112TCA
- Category
- Airplane
- Serial number
- 13154
- Airframe hours
- 2,052
- Engine
- Lycoming IO-360, 180 horsepower, reciprocating
- Damage
- Substantial damage
- Flight
- Personal · Part 91
- Airworthiness certificate
- Standard, Normal
- Last inspection
- Annual · May 14, 2006 · 39 hours before
- Departed
- OQN · West Chester, PA
- Destination
- HWY · Warrenton, VA
- Airport
- OQN · Brandywine, runway 27, 3,347 × 50 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
- 43
- Injuries
- None
- Certificate
- Private
- Airplane ratings
- Single-engine land
- Medical
- Class 3, With waivers/limitations
- Last flight review
- August 11, 2006
- Seat
- Left
- Flight hours
- 132 total · 84 in this make and model · 67 as pilot in command · 14 in the last 90 days · 8 in the last 30 days · 1 in the last 24 hours
Weather
- Conditions
- Visual (VMC) · Day
- Wind
- 270° at 4 knots
- Visibility
- 10 statute miles
- Lowest ceiling
- None
- Temperature
- 50 °F, dew point 28 °F
- Observed at
- KPTW, 14 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.