Aviation Accident Summaries

Aviation Accident Summary NYC93FA044

CLEVELAND, OH, USA

Aircraft #1

N706M

BEECH 18T

Analysis

AFTER ROTATION, DURING THE INITIAL CLIMB, THE NOSE OF THE AIRPLANE PITCHED UP TO APPROXIMATELY 60 DEGREES ABOVE THE HORIZON. THE AIRPLANE CONTINUED TO CLIMB UNTIL ABOUT 250 FEET ABOVE THE GROUND, THEN ROLLED RIGHT, PITCHED DOWN AND DESCENDED. THE AIRPLANE IMPACTED THE GROUND, APPROXIMATELY 45 DEGREES NOSE DOWN, 650 FEET TO THE RIGHT OF THE RUNWAY. POST ACCIDENT INVESTIGATION OF THE WRECKAGE REVEALED THE ELEVATOR JAMMED IN THE FULL UP DEFLECTION. THE UPPER END OF THE ELEVATOR CONTROL ROD WAS FOUND NOT CONNECTED TO THE ELEVATOR, BUT WAS FOUND LAYING AFT, WEDGED BETWEEN THE TAIL CONE AND THE ELEVATOR FARING, HOLDING THE ELEVATOR IN THE FULL UP POSITION. THE CONTROL ROD CONNECTING BOLT WAS FOUND LAYING IN THE BOTTOM OF THE TAIL CONE UNDAMAGED. THE WASHER, NUT AND COTTER PIN RELATED TO THE CONTROL ROD CONNECTING BOLT WERE NOT FOUND. THE ELEVATOR HAD BEEN REMOVED, RECOVERED AND THEN INSTALLED BY COMPANY MAINTENANCE PERSONNEL 166 FLIGHT HOURS PRIOR TO THE ACCIDENT.

Probable Cause and Findings

THE IMPROPER INSTALLATION OF THE ELEVATOR BY COMPANY MAINTENANCE PERSONNEL AND THE LACK OF PROPER INSPECTIONS BY A COMPANY CERTIFIED MECHANIC/INSPECTOR AND THE FAA CERTIFIED MECHANIC WITH INSPECTOR AUTHORIZATION. A FACTOR IN THIS ACCIDENT WAS AN INSUFFICIENTLY DEFINED MAINTENANCE PROCEDURES THAT ALLOWED MULTIPLE MAINTENANCE TASKS TO BE COMBINED INTO A SINGLE LINE ENTRY.

 

Source: NTSB Aviation Accident Database

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