# NTSB NYC94LA088: Aeronca 11AC, N3167E, Berwick, ME, May 21, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: May 21, 1994, 17:38 local (21:38 UTC) - Place: Berwick, ME - Location: 43.2700° N, 70.8624° W: Placed by OpenAirDocs: center of Berwick, ME, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=43.2700&lon=-70.8624&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report December 7, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 38758 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC94LA088 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/38758/pdf - Page: https://openairdocs.org/ntsb/NYC94LA088 ## Probable cause The pilot's inadequate preflight which fail to detect proper operation of the elevator which resulted in the loss of control inflight. A factor is inadequate maintenance which consisted of misrigging of the elevator flight controls. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - vfr pattern - final approach - flt control syst,elevator control (contributing factor) - maintenance,installation - improper, unknown (contributing factor) - aircraft preflight - inadequate, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - grass ## Analysis SHORTLY AFTER TAKEOFF, THE AIRPLANE DESCENDED STEEPLY TO THE GROUND. THE AIRPLANE CRASHED AT THE MIDPOINT OF THE RUNWAY. THE EXAMINATION OF THE AIRPLANE REVEALED THE ELEVATOR FLIGHT CONTROLS WERE MISRIGGED AND THE ELEVATOR OPERATED IN REVERSE TO NORMAL CONTROL INPUTS. THE INSPECTION OF THE ELEVATOR TURNBUCKLE REVEALED THE SAFETY WIRE WAS TIED IN AN UNSATISFACTORY MANNER. ALSO, AN ELEVATOR CONTROL BOLT WAS INSTALLED WITH INADEQUATE CLEARANCE FROM THE AIRFRAME. THIS WAS THE FIRST FLIGHT AFTER AN ANNUAL INSPECTION. THE INSPECTION WAS DONE BY A LICENSED MECHANIC. ON THE DAY OF THE ACCIDENT, THE PILOT WORKED ON THE AIRPLANE FOR SEVERAL HOURS. SAFETY WIRE WAS FOUND INSIDE THE AIRPLANE; SCREWS AND FASTENERS WERE FOUND IN THE PILOT'S PERSONAL EFFECTS. ## Factual narrative On May 21, 1994, at 1738 eastern daylight time, an Aeronca 11AC, N3167E, owned and piloted by Gerard J. Curran, of Somersworth, New Hampshire, struck the ground after takeoff from a private airstrip in Berwick, Maine. The pilot was fatally injured and the airplane was destroyed by the impact. Visual meteorological conditions prevailed and no flight plan had been filed for the flight operating under 14 CFR Part 91. According to a witness at the airport: I heard...taxiing N3167E back and forth on the runway. I was opening the hangar door when I heard him apply takeoff power at the east end of the strip. I went to a window to watch takeoff which would normally be visible from window. The aircraft was not visible at first, but suddenly dropped into view in a vertical dive with no rotation or spin. Heard the engine running at full power. The aircraft immediately impacted approximately half way down the runway.... The FAA reported this was the first flight following an annual inspection. According to the mechanic who accomplished the inspection: ...I did a check of the elevator control system by moving the elevators to the full limits of their travels, at the elevators, to insure that they were going from stop to stop, they were and the control yoke responded properly..... According to FAA Aviation Safety Inspector (Airworthiness) of the Portland Flight Standards District Office, ...the elevator control cables had been incorrectly routed to their perspective attachment point, I.E. the cables attached to the top attachment point at the elevator control was routed directly to the top attachment point at the elevator horn located at the rear most point of the fuselage. The bottom cable was attached to the bottom of the attachment point at the control yoke and routed directly to the lower attachment point of the elevator horn. This arrangement allowed the elevators to deflect downward when the control yoke was moved in the aft direction. Additionally, it was noted that the turnbuckles attached to the control yoke attachment points had been safety wired by a non experienced person, and that there was a difference in the size of the wire. The upper turnbuckle was saftied with .032 wire while the lower turnbuckle was saftied with .041 wire. At the aft section of the fuselage, two (2) discrepancies were noted. The first was the top elevator cable (attached to the top attachment point of the elevator horn) had been routed between the two elevator trim cables. Under operating conditions, this would have caused the larger elevator cable to "saw" through the smaller diameter cable over a period of time. The second discrepancy was the incorrect installation of the bolt securing the elevator cable shackle (p/n AN 115) to the elevator horn. The nut and cotter pin barely missed striking the frame. The opposite side provided a cut out in the frame to allow for clearance of the nut/cotter pin. It was also noted that the top bolt and nut were original, but had a new cotter pin stalled. The lower bolt, nut and cotter pin were new. According to Mr. Paul Hubbard, Aviation Safety Inspector (Airworthiness), Portland Flight Standards District Office, the airplane was involved in an incident in 1992, after which the wings and tail surfaces were removed and the airplane was taken to the pilots residence. The airplane was then transported to Furnas airport. Mr. Hubbard was unable to determined when or where the pilot installed the elevators. In a telephone interview, Mr. Hubbard said the safety wire on the elevator cable turnbuckles had to be cut and the turnbuckles loosed to remove the cables. After installation, the turnbuckles would be tightened to tension the cables, and then safety wired to hold their positions. An autopsy was conducted by Henry F. Ryan, M.D. Chief Medical Examiner, Augusta, Maine, on May 23, 1994. According to Dr. Ryan, a screwdriver, and various screws and fasteners were part of the pilot's personal effects. Toxicological examination conducted by the FAA Civil Aeromedical Institute in Oklahoma City, Oklahoma, was negative for drugs and alcohol. According to the pilot's last medical application dated November 23, 1992, he had a total time of 758 hours. The last entry in the pilot's log book was dated September 24, 1993. It showed a total time of 630 hours. The pilot's recency of experience was not determined. The log book did show 60 hours of flight time in the accident airplane between August 5, 1990 and September 1993. ## Aircraft - Registration: [N3167E](https://openairdocs.org/deregistered/N3167E-2014-09-29), registration cancelled 2014-09-29, S/N 11AC-1507, built 1946 (OpenAirDocs) - Reported make and model: AERONCA 11AC - Registry model: [Aeronca 11AC](https://openairdocs.org/model/aeronca-11ac) (registry code 0191102) (OpenAirDocs) - Registry engine: [Continental C85 series](https://openairdocs.org/engine/continental-c85-series) (registry code 17008, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 11AC-1507 - Airframe hours: 1125 - Engines: CONTINENTAL A-65 65 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Gerard J. Curran - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 19, 1994, 0 hours before - Airport: NONE, Berwick, runway 27, 2,000 × 100 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; private; airplane ratings: single-engine land, single-engine sea; medical: class 3, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 630 total, 60 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 200° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 39 °F - Altimeter: 29.00 inHg - Observed at: SFM, 12 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 19940521011909A](https://openairdocs.org/incident/19940521011909A), May 21, 1994: Bbavia 11AC, Berwick, ME, Destroyed, 1 fatal. Nose dived onto runway on climbout. Elevator cables installed backwards by pilot. Other non approved installations. ## Other investigations on N3167E (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 MIA87LA149](https://openairdocs.org/ntsb/MIA87LA149), Apr 28, 1987: Aeronca 11AC (N3167E), Daytona Beach, FL, substantial damage 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.