Sarasota, FL, USA
N24485
Cessna 172S
The student pilot stated she encountered an autopilot trim failure on initial takeoff climb. She attempted to disconnected the autopilot with the autopilot disconnect red button on the control yoke with negative results. She stated she had not received any training on the autopilot system by the operator. Review of her training records supported her statement. Title 14 CFR Part 91.9 requires the pilot to comply with the operating limitations in the airplane flight manual. The airplane flight manual for the Cessna 172S requires the pilot to commit to memory the four step procedure for autopilot, autopilot trim, or electric trim malfunction. The student pilot did not comply with the written instruction in the flight manual and experienced a loss of aircraft control on landing (porpoise on runway) resulting in a hard landing on the nose gear. Examination of the autopilot before removal from the airplane and at the factory revealed no abnormalities were noted.
On November 11, 2001, at 1051 eastern standard time, a Cessna 172S, N24485, registered to Eagle Aviation, operating as a 14 CFR Part 91 training flight, crashed on landing at the Sarasota-Bradenton International Airport, Sarasota, Florida. Visual meteorological conditions prevailed and no flight plan was filed. The airplane sustained substantial damage. The student pilot reported no injuries. The local training flight originated from Sarasota, Florida, at 1048. The student pilot stated she departed from runway 04 and experienced trim problems after the airplane was rotated for takeoff. The student pilot further reported that, during the initial climb, the nose of the airplane kept wanting to tuck down. She informed the control tower that she was having difficulty keeping the airplane in the air. The controller cleared her to land on runway 32. She attempted to manually control the airplane with trim, but was unsuccessful. She put both hands on the control wheel and activated the autopilot red disconnect button with negative results because she knew she was not flying the airplane. She did not attempt to turn the autopilot off at the control head because she had not received any training and did not know how to do so. Review of training records on file by the operator for the student pilot confirmed that she had not received any training on the autopilot system. The student pilot stated that while on final approach she applied full flaps and power. The airplane continued to experience a trim problem. The airplane touched down on the runway and began to porpoise, became airborne, and touched back down on the runway. The airplane veered to the right off the runway about 500 feet from the end of the runway and the nose pitched down. When asked if the airplane collided in a nose down attitude at any time on the runway she could not recall if it did or did not. The Operations Supervisor at Sarasota Tower stated that he observed N24485 on takeoff from runway 04. The controller informed him that the pilot stated she was having difficulty in keeping the airplane in the air. The controller cleared the pilot to land on runway 32. He observed the airplane at about 500 feet over the numbers of runway 32 in a high rate of speed. The attitude of the airplane changed to a nose down attitude and the airspeed appeared to increase. He did not think the airplane would land on the runway and notified the fire department on the crash phone. The airplane was observed about 3,000 feet down the runway in a high rate of descent when it was observed to begin a flare about 10 feet over the runway. It appeared to him that the pilot had over corrected and the airplane climbed without touching the runway. The airplane was observed to come back down and impact the runway in a nose down attitude about 3, 600 feet down the runway. It immediately started to porpoise, became airborne, collided with the runway in a nose down attitude on the nose wheel, became airborne, and collided with the runway in a nose down attitude about 500 feet from the end of the runway. The nose gear collapsed and the airplane went off the right side of the runway. A pilot stated that on October 28, 2001, that he and his instructor were taxing to runway 04 in N24485. During the before take-off checklist he noticed the trim tab turning itself up and down as he was taxing to the hold short line. He showed it to his instructor and he was instructed to disengage the autopilot by pressing the button on the yoke. The autopilot did not disengage. He reached out and disengaged the autopilot by using the autopilot button on the autopilot. Another pilot stated that on October 17, 2001, that while on final for a VOR approach in N24485 that he tried to disengage the autopilot by pushing the red button and it would not disengage. Neither pilot reported the discrepancy to the operator. Examination of the airplane was conducted by the FAA and Parties to the NTSB investigation. Examination of the fuselage showed no signs of damage. The firewall was buckled and the cabin floor aft of the firewall was buckled. The autopilot system functioned normally when checked on the ground. The autopilot components were removed and given to the FAA inspector on scene. The components were transported to the manufacturer and tested in the presence of the FAA and the NTSB investigator-in-charge. No abnormalities were noted. The investigation revealed that the autopilot could be inadvertently engaged by pressing the heading, altitude, or autopilot button. The aircraft manufacturer and autopilot manufacturer are incorporating an autopilot software and checklist change into a single service bulletin. (For additional information see Cessna Aircraft Company Mishap Report and Honeywell KAP 140 Autopilot tests, attachments to this report.) Review of 14 CFR Part 91.9 Civil aircraft flight manual, marking, and placard requirements states in Para (a) "Except as provided in paragraph (d) of this section, no person may operate a civil aircraft without complying with operating limitations specified in the approved Airplane or Rotorcraft Flight Manual, markings and placards, or as otherwise prescribed by the certificating authority of the country of registry." The Cessna 172S Skyhawk Information Manual states in Section 4, NORMAL PROCEDURES, INTRODUCTION "Section 4 provides checklist and amplified procedures for the conduct of normal operation. Normal procedures associated with optional systems can be found in the Supplements, Section 9." Review of Chapter 4 NORMAL PROCEDURES BEFORE TAKEOFF states, "19. Autopilot (If installed)-Off." Review of SECTION 9-SUPPLEMENTS, SECTION 3, EMERGENCY PROCEDURES states, "The four step procedure listed under paragraph A should be among the basic airplane emergency procedures that are committed to memory. It is important that the pilot be proficient in accomplishing all four steps without reference to this manual. 1. In case of Autopilot, Autopilot Trim, or Manual Electric Trim malfunction (accomplish items A and B simultaneously): A. Airplane Control Wheel-GRASP FIRMLY and regain aircraft control. B. A/P DISC/TRIM INT Switch- PRESS and HOLD throughout recovery. C. AIRCRAFT-RE-TRIM Manually as Needed. D. AUTO PILOT Circuit Breaker-PULL.." The wreckage of N24485 was released to Mr. Eugene A. Crtelli, Managing Partner, Eagle Aviation Academy LLC on November 19, 2001. The autopilot components were released to Mr. Crtelli on December 11, 2001.
The operators failure to ensure adequate training had been provided to the student pilot in autopilot operations, and the student pilot's failure to comply/ follow written instructions (Federal Regulations/172 Skyhawk Information Manual) pertaining to the failure of the autopilot, autopilot trim, or manual electric trim malfunction. This resulted in a reported failure of the autopilot trim to disconnect on initial takeoff for undetermined reasons, loss of aircraft control on landing (porpoise), and subsequent hard landing on the nose gear.
Source: NTSB Aviation Accident Database
Aviation Accidents App
In-Depth Access to Aviation Accident Reports
