1 fatality

2019-04-18: Beechcraft 60 Duke (N65MY) — KMA Technology Solutions — Fullerton, United States of America

Fullerton, United States of AmericaTakeoff (climb)

On April 18, 2019, a Beechcraft 60 Duke (registration N65MY) operated by KMA Technology Solutions was involved in an aviation accident near Fullerton, United States of America during takeoff. One person was killed. Investigators recorded the probable cause as: The pilot’s use of an unapproved elevator control lock device, and his failure to remove that device and correctly position the elevator before flight, which resulted in a loss of control during takeoff. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781191017Data APIEditorial standards

A pilot's use of an unapproved elevator control lock device and failure to remove it before flight resulted in a loss of control during takeoff, destroying the airplane. The pilot did not perform a preflight inspection or control check.

Introduction

An accident occurred during the takeoff roll of a general aviation airplane in visual meteorological conditions. The airplane became airborne about 1,300 feet down the runway, which was approximately 75% of the normal ground roll distance for the airplane’s weight and the takeoff environment.

Accident Sequence

About two seconds after rotation, the airplane rolled left. Three seconds later, the airplane reached an altitude of about 80 feet above ground level and was in a 90° left bank. The nose then dropped as the airplane rolled inverted and struck the ground in a right-wing-low, nose-down attitude. The airplane was destroyed.

Postaccident Examination

Postaccident examination revealed no anomalies with the airframe or engines that would have precluded normal operation. The landing gear, flap, and trim positions were appropriate for takeoff, and flight control continuity was confirmed. The symmetry of damage between both propeller assemblies indicated that both engines were producing equal and high amounts of power at impact. An autopsy revealed no natural disease that could pose a significant hazard to flight safety.

Elevator Lock Findings

Review of surveillance video footage from before the accident showed that the elevator was in the almost full nose-up (trailing edge up) position during the taxi and the beginning of the takeoff roll. The footage also indicated that the pilot did not perform a preflight inspection of the airplane or a control check before the accident flight. According to the pilot’s friend, who was also in the hangar, the pilot had manipulated and locked the elevator in the trailing edge up position on the night before the accident to clear an obstacle in the hangar. No evidence of an installed elevator control lock was found in the cabin after the accident. Therefore, the pilot likely used an unapproved object placed between the elevator balance weight and the trailing edge of the horizontal stabilizer to lock the elevator.

Pilot Actions and Distractions

The pilot’s friend reported that the pilot was running about one hour late on the day of the accident. The night before, the pilot was troubleshooting an electrical issue that caused a circuit breaker to keep tripping, which may have become a distraction. After pulling the airplane out of the hangar, the pilot directed his attention to the arrival of a motorbike in the hangar alley, which likely distracted him and further delayed his departure. The pilot did not conduct a preflight inspection or control check, due either to distraction or time pressure.

Probable Cause

The pilot’s use of an unapproved elevator control lock device, and his failure to remove that device and correctly position the elevator before flight, which resulted in a loss of control during takeoff. Contributing to the accident was his failure to perform a preflight inspection and control check, likely in part because of distractions before boarding and his late departure time.