Pilot Debrief

Beech A36 near Summerland Key, FL — 2020-01-25

Final reportERA20LA089
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Date
2020-01-25
Location
Summerland Key, FL, USA
Airport
FD51
Aircraft
Beech A36
Registration
N41VK
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Takeoff roll

Probable cause

The pilot's failure to remove the flight control gust lock before takeoff, which resulted in an inability to rotate, aborted takeoff, and subsequent runway overrun. Contributing to the accident was a missing piece of the flight control gust lock, which did not give the pilot the intended warning that the gust lock was engaged.

NTSB narrative

The pilot reported that he performed preflight inspection and run-up checks before takeoff, which included a check of the elevator flight control system with no discrepancies noted. During the takeoff roll, the pilot reported the airplane was "nosing down to the front." He twice adjusted the elevator trim toward the airplane nose-up direction then applied aft input on the control yoke to rotate at 85 knots but felt resistance and aborted the takeoff. The airplane exited the runway, and the right wing impacted trees. The airplane’s right wing was substantially damaged during the runway excursion. Shortly after the accident, the pilot reported to the airport manager that he could not get airborne because of "…the control lock or something." The airport manager reported seeing the flight control gust lock on the right wing (and that it was not stored in a container behind the airplane’s rear seats as reported by the pilot). Postaccident examination of the elevator primary flight control system revealed no evidence of preimpact failure or malfunction that would have precluded normal operation. Additionally, comparison of a postaccident photograph of the elevator position with the gust lock installed with the elevator position observed in a video of the accident takeoff roll indicated similar elevator positions: trailing edge down (airplane nose down), which was consistent with the pilot reported nose-down condition during the takeoff roll. Given this information, it is likely that the pilot had not removed the gust lock prior to initiating the takeoff, which resulted in his inability to rotate the airplane. A postaccident photograph of the gust lock also showed that it was missing a portion designed to cover the engine controls and prevent engine start with the lock installed. Although the airframe manufacturer had previously published a service bulletin pertaining to the gust lock, it was for a different reason and did not require an inspection to make sure a proper and complete device was available. Had the gust control lock been complete, it would have blocked the engine controls and provided the intended warning.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot did not use the gust control lock before takeoff.

NTSB coding

Evidence available

  • Photos
  • 9 docket documents
View NTSB final reportView NTSB docket

Docket documents9

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