# NTSB NYC89FA093: Piper PA-31-350, N40978, Toms River, NJ, March 2, 1989 - Type: NTSB accident investigation - Classification: Accident · No injuries · Field investigation · Final report - Date: March 1, 1989, 19:51 local (Mar 2, 1989, 00:51 UTC) - Place: Toms River, NJ - Location: 39.9537° N, 74.1979° W: Placed by OpenAirDocs: center of Toms River, NJ, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=39.9537&lon=-74.1979&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report September 30, 1991 - Report: Approved by Office Director - NTSB case key (mKey): 36274 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC89FA093 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/36274/pdf - Page: https://openairdocs.org/ntsb/NYC89FA093 ## Probable cause FAILURE OF THE PILOT TO MAINTAIN AIRSPEED AND CONTROL OF THE AIRCRAFT, AND HIS EXCEEDING THE DESIGN STRESS LIMITS OF THE AIRCRAFT. FACTORS RELATED TO THE ACCIDENT WERE: AUTOPLT MALFUNCTION DUE TO IMPROPER INSTALLATION BY MAINTENANCE PERSONNEL AND THE PILOT'S FAILURE TO PREFLIGHT THE AUTOPILOT BEFORE USING IT IN FLIGHT. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Altitude deviation,uncontrolled, cruise - autopilot/flight director - erratic (contributing factor) - maintenance,installation - improper, other maintenance personnel (contributing factor) - aircraft preflight - inadequate, pilot in command (contributing factor) - autopilot - improper use of, pilot in command (contributing factor) - Loss of control - in flight, cruise - airspeed - not maintained, pilot in command (cause) - aircraft control - not maintained, pilot in command (cause) - Airframe/component/system failure/malfunction, maneuvering - flight control,elevator - overload - design stress limits of aircraft - exceeded, pilot in command (cause) ## Analysis THE ACFT WAS CRUISING AT 8500 FT WHEN IT EXPERIENCED AN INFLT LOSS OF CONTROL. THE PLT SAID THE AUTOPILOT PITCH TRIM RAN AWAY NOSE DOWN & HE WAS UNABLE TO DISCONNECT THE AUTOPILOT PRIOR TO THE LOSS OF CONTROL. EXAM OF THE ACFT SHOWED THE LEFT ELEVATOR HORN WAS BENT DOWN & THE RIGHT ELEVATOR HORN WAS BROKEN OFF. THE AUTOPILOT WAS EXAMINED & ALL DISCONNECTS EXCEPT FOR THE ACCELEROMETER TEST FUNCTIONED PROPERLY. THE PITCH TRIM BOARD WAS FOUND IMPROPERLY INSTALLED IN THE AUTO PILOT & DID NOT MAKE CONNECTION. WITH THE ALTITUDE HOLD ENGAGED, THE AUTOPILOT WOULD HOLD THE ELEVATOR POSITION AT TIME OF ENGAGEMENT & TRIM TO KEEP THE FORCES NEUTRAL. IF THE AIRCRAFT SLOWED, IT WOULD LOSE ALTITUDE & TRIM NOSE UP. RADAR DATA SHOWED THE ACFT STARTED TO SLOW, THEN DESCENDED FROM 8500 TO 8300 FT, THEN CLIMBED TO 8900 FT. THE ACFT THEN CAME DOWN VERY RAPIDLY TO 1700 FT PRIOR TO A RECOVERY. RPRTDLY, THE PLT DID NOT TEST THE AUTOPLT BEFORE TAKEOFF. . ## Aircraft - Registration: [N40978](https://openairdocs.org/aircraft/N40978), registered now, S/N 31-8152199, built 1981 (OpenAirDocs) - Reported make and model: PIPER PA-31-350 - Registry model: [Piper PA-31-350](https://openairdocs.org/model/piper-pa-31-350) (registry code 7103110) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 31-8152199 - Airframe hours: 4131 - Engines: LYCOMING IO-540-J2B2 350 horsepower reciprocating - Damage: Substantial damage - Flight: Part 91 - Operator: Falcon Flight Center - Registered owner: Ranger Air Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 25, 1989, 5 hours before - Departed: HFD, HARTFORD, CT - Destination: ACY, ATLANTIC CITY, NJ ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 26; airline transport, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 2,300 total, 300 in this make and model, 2,000 as pilot in command, 120 in the last 90 days, 40 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Visibility: 20 statute miles - Lowest ceiling: none ## 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 19890301002899A](https://openairdocs.org/incident/19890301002899A), Mar 1, 1989: Piper PA31350, Toms River, NJ, Substantial damage. Reported runaway pitch down trim. Circuit board installed incorrectly. Exact cause unknown. Pull up caused damage. ## Other investigations on N40978 (1) 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. - [NTSB CHI06CA181](https://openairdocs.org/ntsb/CHI06CA181), Jul 11, 2006: Piper PA-31-350 (N40978), Indianapolis, IN, substantial damage. Probable cause: The failure of the tug driver to maintain clearance from the airplane taxiing on an active taxiway. A factor was the night conditions. 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.