Pilot Debrief

CESSNA 340A near Tatum, TX — 2021-04-19

Final reportCEN21FA195
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Date
2021-04-19
Location
Tatum, TX, USA
Airport
GGG
Aircraft
CESSNA 340A
Registration
N801EC
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Initial climb

Probable cause

The pilot’s loss of airplane control for undetermined reasons.

NTSB narrative

The pilot was planning to perform a functional test of the airplane’s newly upgraded autopilot system. Automatic dependent surveillance broadcast data showed that, after takeoff, the airplane turned east and climbed to 2,750 ft. Air traffic control information indicated that the controller cleared the pilot to operate under visual flight rules to the east of the airport. Communications between ground control, tower control, and the pilot were normal during the ground taxi, takeoff, and climb. Radio and radar communications were lost 6 minutes after takeoff, and no radio distress calls were received from the pilot. The airplane impacted wooded terrain about 3/4 mile to the east of the last recorded radar data point. Groundspeeds and headings were consistent throughout the flight with no abrupt deviations. The airplane impacted the wooded terrain in a nose-down, near-vertical flight attitude. Most of the airplane, including the fuselage, wings, and empennage, were consumed by a postimpact fire. Both engines and propellers separated from the airplane at impact with the ground. Examination of the engines revealed no preaccident failures or malfunctions that would have precluded normal operations. Both propellers showed signs of normal operation. Flight control continuity was confirmed. The elevator trim cables stop blocks were secured to the cables and undamaged. They were found against the forward stop meaning the trim tab was at full down travel (elevator leading edge full down) which indicated that the airplane was trimmed full nose up at impact. The airplane’s cabin sustained fragmentation from impact and was consumed by fire; as a result, the autopilot system could not be examined. The investigation was unable to determine why the pilot lost control of the airplane.

Analysis

Primary failure mode
Automation / mode confusion
First missed decision gate
Pilot should have delayed autopilot engagement until reaching 5000 ft.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • Photos
  • 16 docket documents
View NTSB final reportView NTSB docket

Docket documents16

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