West Palm Beach, FL, USA
N8132Q
CESSNA 414
The copilot, who was seated in the right seat, reported that after an uneventful run-up and taxi, the pilot, who was seated in the left seat, initiated the takeoff. The airplane remained on the runway past the point at which takeoff should have occurred and the copilot observed the pilot attempting to pull back on the control yoke but it would not move. The copilot then also attempted to pull back on the control yoke but was also unsuccessful. Observing that the end of the runway was nearing, the copilot aborted the takeoff by reducing the throttle to idle and applying maximum braking. The airplane overran the runway into rough and marshy terrain, where it came to rest partially submerged in water. Postaccident examination of the airplane and flight controls found no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. Specifically, examination of the elevator flight control rigging, in addition to functional checks of the elevator, confirmed continuity and normal function. Additionally, the flight control lock was found on the floor near the rudder pedals on the left side of the cockpit. Due to a head injury sustained during the accident, the pilot was unable to recall most of the events that transpired during the accident. The pilot did state that he typically removed the control lock during the preflight inspection and that he would place it in his flight bag. He thought that a shoulder injury may have led to the control lock missing the flight bag, and why it was found behind the rudder pedals after the accident. Review and analysis of a video that captured the airplane during its taxi to the runway showed that the elevator control position was similar to what it would be with the control lock installed. While the pilot and copilot reported that they did not observe the control lock installed during the takeoff, the position of the elevator observed on the video, the successful postaccident functional test of elevator, and the unsecured flight control lock being located behind the pilot’s rudder pedals after the accident suggest that the control anomaly experienced by the pilots may have been a result of the control lock remaining inadvertently installed and overlooked by both pilots prior to the takeoff. According to the airframe manufacturer’s preflight and before takeoff checklists, the flight control lock must be removed during preflight, prior to engine start and taxi, and the flight controls must be checked prior to takeoff. Regardless of why the elevator control would not move during the takeoff, a positive flight control check prior to the takeoff should have detected any such anomaly. It is likely that the pilot failed to conduct a flight control check prior to takeoff. Further, the pilot failed to abort the takeoff at the first indication that there was a problem. Although delayed, the copilot’s decision to take control of the airplane and abort the takeoff likely mitigated the potential for more severe injury to the occupants and damage to the airplane.
On October 8, 2020, about 1115 eastern daylight time, a Cessna 414, N8132Q, was substantially damaged when it was involved in an accident at North Palm Beach County General Aviation Airport, (F45) West Palm Beach, Florida. The two private pilots and five passengers sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the multiengine-rated private pilot seated in the right front seat (copilot), after engine start and taxi, the pilot performed a runup and did not notice any irregularities. As the pilot taxied the airplane onto the runway for takeoff, the copilot checked the takeoff trim setting, which gave him a clear view of the pilot’s control yoke and he did not notice the presence of the control lock. The pilot then applied the brakes and advanced the throttles to full power. Once at full RPM, the pilot released the brakes, and they began the takeoff roll. Shortly into the takeoff roll, the copilot felt a “slight shudder,” which appeared to come from the controls, but it only lasted for a moment. As they continued down the runway, he realized they should have rotated for liftoff; he observed the airspeed indicator, and they were about 10 to 15 mph past “blueline” (119 mph), but the airplane remained on the runway and continued to accelerate. The copilot looked at the pilot, who was looking down at the controls and trying to determine why he was unable to move the control yoke. The copilot attempted to pull back on the control yoke as well, but the controls would not move. He aborted the takeoff by pulling the throttles to idle and applying maximum braking. He estimated they were doing between “120 and 130 knots” when the takeoff was aborted. The airplane came to rest about 450 ft beyond the departure end of runway 14. Two distinct tire skid marks for the left and right main landing gear were visible departing the right side of the runway adjacent to the numbers of runway 32. The tire marks continued through the grass and mud for 575 ft before the airplane impacted the mound with the right wing. The airplane spun around and came to rest nose down in a marshy area and was partially submerged in about 5 ft of water. The fuselage, wings, and empennage sustained substantial damage. The pilot reported he performed the preflight, taxi, and runup according to the checklist and there was nothing unusual. The pilot further stated that he always removes the control lock per the checklist and that, when the flight controls appeared jammed during the accident takeoff roll, he looked down and observed that there was no control lock in place. He also stated that when he removes the control lock, he puts it in his flight bag but that a shoulder injury may have led to the control lock missing the flight bag and that’s why the control lock was found behind the rudder pedals. Due to his head injury, he remembered no additional details about the accident. During a follow-up interview, when asked the copilot stated he could not recall if the pilot left the control lock installed during preflight, or whether the pilot may have attempted to remove it during the takeoff roll. During impact, the stabilizer/elevator assembly was torn from its attachments, but both sides (left and right) remained attached to their respective locations and the elevator control rigging was intact and operational. The control lock holes for both left and right sides yokes had no signs of elongation or damage. Examination of the elevator flight control rigging in addition to functional checks of the elevator confirmed continuity and functionality of the elevator. No pre-impact anomalies with the airframe or flight controls were noted during the examination. The control lock was located on the left side of the cockpit under the far-left rudder/brake pedal and showed no signs of damage. The control lock was about 12 inches long and consisted of a metal rod in a “seven” shape that slid into the control yoke on one end and on the opposing end there was a red and yellow streamer attached. Witness and airport surveillance videos were sent to the NTSB Vehicle Recorders division for a detailed video study. The witness video showed the airplane as it began to taxi on the ramp. Still images captured from the video show the elevator was in the trailing-edge-down position with the elevator horns above the horizontal stabilizer. An exemplar airplane with a control lock installed was used for reference and showed the elevator in a trailing-edge-down position with the elevator horns above the horizontal stabilizer surface. The accident airplane’s exact elevator position, although similar to the exemplar airplane with a control lock installed, could not be calculated from the still images (see figure 1). Figure 1 – Still frame from video footage of the accident airplane’s elevator during taxi (left) compared to the elevator on an exemplar airplane with a control lock installed (right). Footage from a third video showed the airplane as it accelerated down the runway. A review of all three videos determined that the airplane was accelerating through 100 knots with about 1,800 ft (of a total 4,300 ft) of runway remaining. Airport security camera footage showed the airplane proceeding down the last third of the runway as it departed the right side of the paved surface before colliding with a dirt mound and disappearing out of view Airplane performance data indicated that the airplane should have taken off at 2,185 ft down the 4,300 ft long runway. The weight and balance of the airplane were within center of gravity and weight limitations. According to the manufacturer’s preflight checklist and before takeoff checklist, the flight control lock must be removed prior to engine start, and the flight controls must be checked prior to takeoff.
The pilot’s inadequate preflight inspection during which he failed to detect a flight control abnormality, and his failure to expediently abort the takeoff, which resulted in the co-pilot performing a delayed aborted takeoff and the subsequent runway overrun.
Source: NTSB Aviation Accident Database
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