SEA07LA046

NTSB accident investigation · Cessna TR182 · San Diego, CA · January 11, 2007

Accident · Serious injuriesLimited investigationFinal report
Date
January 11, 2007, 12:11 local (20:11 UTC)
Place
San Diego, CA
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N5443SCessna TR182
Weather
Visual (VMC) · Day
Status
Completed · report August 30, 2007
Report
Approved by Office Director
Parties
Federal Aviation Administration, Cessna Aircraft Company
FAA report
20070111006999A
Case key
65140

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's failure to maintain control of the airplane during takeoff. A contributing factor to the accident was the improper takeoff configuration of the airplane.

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 - in flightTakeoff
Procedures/directives - not followedPilot in commandFactor
Aircraft control - not maintainedPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - runway

Analysis

The airplane impacted the runway in a nose-down attitude during the takeoff initial climb out. The 79-year old pilot was departing on a short flight to his home airport when the accident occurred. According to a witness, the airplane climbed to 100 feet and suddenly pitched nose-down. The airplane continued in this attitude until ground impact. Post accident examination of the airplane control systems did not reveal any operational anomalies. Investigators noted that the trim tab was set 10 degrees nose down and the flaps were extended to 40 degrees. Both of these control positions are inconsistent with normal takeoff settings as specified by the airplane manufacturer.

Factual narrative

History of flight

On January 11, 2007, at 1211 Pacific standard time, a Cessna TR182, N5443S, collided with runway 23 shortly after takeoff from Montgomery Field Airport, San Diego, California. The pilot was operating the airplane under the provisions of 14 CFR Part 91 as a personal flight. The commercial pilot, the sole occupant, sustained serious injuries. The airplane was substantially damaged. Visual meteorological conditions prevailed and an instrument flight rules flight plan was in effect. The pilot was destined for McClellan- Palomar Airport, Carlsbad, California.

According to a witness, the airplane was departing runway 23. The takeoff roll and initial climb appeared normal. When the airplane reached about 100 feet above ground level, the nose pitched down and remained in this attitude until it impacted the ground. The main wreckage came to rest approximately 700 feet from the end of runway 23 and just off its right side.

According to line personnel based at Montgomery Field, the pilot requested that his battery be recharged. They used a ground vehicle and successfully recharged the airplane's battery using the 12-volt receptacle on the airplane. The pilot then taxied the airplane to the active runway and departed.

A representative from Cessna Aircraft Company responded to Montgomery Field and examined the airplane in a hangar with the Federal Aviation Administration accident coordinator present. The right flap appeared extended 40 degrees. The left flap appeared extended 10 degrees. The trim tab was measured at 10 degrees tab up. Photographs obtained from initial responders showed these approximate settings at the accident site.

Personnel information

The 79-year old pilot held a commercial pilot certificate and was certified to fly single and multi engine airplanes, as well as fly in instrument conditions. His last medical, a third class, was issued on January 5, 2006. It had no limitations or waivers. A review of the pilot's flight logbook showed that he had a total flight time of 2,807 hours. He had flown 13 hours in the past 90 days, 2 hours in the last 30 days, and 1 hour in the 24 hours preceding the accident.

The pilot's son was interviewed by the National Transportation Safety Board investigator. His father was unable to be interviewed regarding the accident, and could not recall the events leading up to the accident. The pilot's son further stated that medical personnel did not find any evidence of an incapacitating medical event that may have initiated the accident sequence.

Aircraft information

The last annual inspection was completed on the airplane on April 11, 2006, at a tachometer time of 1,224.7 hours and a total airframe time of 3,275.6 hours.

According to the airplane Pilot's Operating Handbook, the wing flaps should be set from 0 to 20 degrees, and the trim should be set at the takeoff position prior to departure. According to a representative from Cessna Aircraft Company, takeoff position is near 0 degrees elevator trim tab deflection.

Tests and research

The airplane was examined on February 1, 2007, at Aircraft Recovery Service, Littlerock, California. The National Transportation Safety Board (NTSB) investigator and a Cessna representative were present.

The control cables were traced throughout the wreckage and were continuous. The trim and autopilot switches were in the "OFF" position. The airplane was supplied power from its battery. When tested, the battery held 24.6 volts of electricity. The master and avionics switches were turned to the "ON" positions. The autopilot and trim switches (manufactured by S-Tec Corporation) were initially in the "OFF" position and did not power up when the system was supplied with power. Once the switches were placed in the "ON" positions, both systems activated. Preflight tests were conducted using the S-Tec operator's manual and produced corresponding activation to the autopilot and trim units.

The Aero Trim system installation was examined in the left wing. The unit contained a servo, positioned in the aileron that connected to a power connector located in the wing. The plug that ran from the servo to the wing connect point was loose within the structure. The plug was visible, and in a position between the aileron control surface and wing structure. With the plug in this position, the ailerons could not be moved and were locked into place. When investigators examined the connect point in the wing, they noted that the plug end was capped off with a rubber fitting, and the wire was clamped so that it could not extend outside of the wing structure. The electrical lead on the servo side of the system within the aileron was found loose and there was no evidence of the wire having been secured.

The flap system was powered using the airplane battery. At the flap selector, the handle indicated 10 degrees of flaps. Investigators noted that the instrument panel and flap actuation unit were bent aft and upward into the cabin area, approximately 20 degrees from the instrument panel's original design. Measurement of the flap actuator screw showed 6 inches of threads, which according to the Cessna representative, was consistent with a flap extension of 40 degrees. With power applied, there was no movement of the flap actuator. When investigators moved the flap selector from 0 degrees to 10 degrees, the cam moved from the UP microswitch to the DOWN microswitch. Due to the lack of tension on the flap follow up cable as a result of the accident sequence, investigators manually actuated both microswitches and they responded appropriately. The cables were continuous from the flap selector outboard to the flaps. Follow up cable tension prior to the accident could not be ascertained.

According to the Cessna representative, the elevator trim tab measurement of approximately 10 degrees tab up equated to a nose down attitude.

Additional information

The wreckage was released to the owner's representative on April 17, 2007. No parts or pieces were retained by the NTSB.

Aircraft

Registration
N5443S
Reported as
Cessna TR182
Category
Airplane
Serial number
R18201572
Airframe hours
1,243
Engine
Textron Lycoming O-540-L3C5D, 235 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
KVZ Corp
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 1, 2006 · 18 hours before
Departed
MYF · San Diego, CA
Destination
CRQ · Carlsbad, CA
Flight plan
IFR
Airport
MYF · Montgomery Field, runway 23, 3,400 × 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
79
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
January 1, 2005
Seat
Left
Flight hours
2,807 total · 2,563 as pilot in command · 13 in the last 90 days · 2 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 10 knots
Visibility
10 statute miles
Lowest ceiling
3,400 ft broken
Temperature
57 °F, dew point 46 °F
Altimeter
29.95 inHg
Observed at
MYF

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.