Pilot Debrief

BEECH V35A near Statesboro, GA — 2023-06-01

Final reportERA23LA253
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Date
2023-06-01
Location
Statesboro, GA, USA
Airport
TBR
Aircraft
BEECH V35A
Registration
N8074R
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Approach

Probable cause

Maintenance personnel’s improper installation of the pitch servo bridle cable clamp, which led to binding in the elevator control system that restricted aft yoke movement during the landing approach.

NTSB narrative

The pilot reported that the purpose of the flight was to test the newly installed autopilot servos and calibrate the fuel flow sensor. The pilot stated that the control surfaces moved as expected during the preflight inspection. Near the end of the flight, the autopilot did not turn to a programmed waypoint. The pilot disconnected the autopilot and took over manual control of the airplane but was unable to prevent an unintended nose-down pitch. Despite verifying the autopilot disconnection, the yoke was unresponsive and the airplane continued to descend on the final approach, striking a light pole about 1,000 ft short of the runway threshold before impacting the ground. Postaccident examination of the airplane revealed that the pitch servo bridle cable clamp had not been properly installed, which resulted in the cable binding when the yoke was pulled aft. The installer had not verified that the required clearance was maintained and did not perform the necessary post-installation control movement checks as specified in the autopilot’s installation instructions. The incorrect positioning of the bridle cable clamp resulted in restricted elevator control, which prevented the pilot from recovering from the nose-down condition during the approach.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Installer failed to verify proper installation of the autopilot system before flight.

NTSB coding

Evidence available

  • Video
  • Photos
  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10

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