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Aviation safety reports, made easier to study

NTSB Reports is an independent research and search tool for public aviation accident and incident records. It brings NTSB aviation reports, structured fields, docket files, extracted figures, photos, videos, and update history into one searchable interface.

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NTSB Report

March 2, 1989 · Piper PA-31-350 · N40978

Toms River, NJ

Overview

Report Status
Probable Cause
Event Type
Accident
Date
March 2, 1989
Injury Outcomes
No injuries (1 uninjured)
Location
Toms River, NJ
Aircraft
Piper PA-31-350
Tail Number
N40978
Operator
Falcon Flight Center
Injuries
None
Aircraft Damage
Substantial
NTSB Number
NYC89FA093

THE ACFT WAS CRUISING AT 8500 FT WHEN IT EXPERIENCED AN INFLT LOSS OF CONTROL. THE PLT SAID THE AUTOPILOT PITCH TRIM RAN AWAY NOSE DOWN & HE WAS UNABLE TO DISCONNECT THE AUTOPILOT PRIOR TO THE LOSS OF CONTROL. EXAM OF THE ACFT SHOWED THE LEFT ELEVATOR HORN WAS BENT DOWN & THE RIGHT ELEVATOR HORN WAS BROKEN OFF. THE AUTOPILOT WAS EXAMINED & ALL DISCONNECTS EXCEPT FOR THE ACCELEROMETER TEST FUNCTIONED PROPERLY. THE PITCH TRIM BOARD WAS FOUND IMPROPERLY INSTALLED IN THE AUTO PILOT & DID NOT MAKE CONNECTION. WITH THE ALTITUDE HOLD ENGAGED, THE AUTOPILOT WOULD HOLD THE ELEVATOR POSITION AT TIME OF ENGAGEMENT & TRIM TO KEEP THE FORCES NEUTRAL. IF THE AIRCRAFT SLOWED, IT WOULD LOSE ALTITUDE & TRIM NOSE UP. RADAR DATA SHOWED THE ACFT STARTED TO SLOW, THEN DESCENDED FROM 8500 TO 8300 FT, THEN CLIMBED TO 8900 FT. THE ACFT THEN CAME DOWN VERY RAPIDLY TO 1700 FT PRIOR TO A RECOVERY. RPRTDLY, THE PLT DID NOT TEST THE AUTOPLT BEFORE TAKEOFF. .

NTSB Probable Cause

FAILURE OF THE PILOT TO MAINTAIN AIRSPEED AND CONTROL OF THE AIRCRAFT, AND HIS EXCEEDING THE DESIGN STRESS LIMITS OF THE AIRCRAFT. FACTORS RELATED TO THE ACCIDENT WERE: AUTOPLT MALFUNCTION DUE TO IMPROPER INSTALLATION BY MAINTENANCE PERSONNEL AND THE PILOT'S FAILURE TO PREFLIGHT THE AUTOPILOT BEFORE USING IT IN FLIGHT.

Full Narrative

THE ACFT WAS CRUISING AT 8500 FT WHEN IT EXPERIENCED AN INFLT LOSS OF CONTROL. THE PLT SAID THE AUTOPILOT PITCH TRIM RAN AWAY NOSE DOWN & HE WAS UNABLE TO DISCONNECT THE AUTOPILOT PRIOR TO THE LOSS OF CONTROL. EXAM OF THE ACFT SHOWED THE LEFT ELEVATOR HORN WAS BENT DOWN & THE RIGHT ELEVATOR HORN WAS BROKEN OFF. THE AUTOPILOT WAS EXAMINED & ALL DISCONNECTS EXCEPT FOR THE ACCELEROMETER TEST FUNCTIONED PROPERLY. THE PITCH TRIM BOARD WAS FOUND IMPROPERLY INSTALLED IN THE AUTO PILOT & DID NOT MAKE CONNECTION. WITH THE ALTITUDE HOLD ENGAGED, THE AUTOPILOT WOULD HOLD THE ELEVATOR POSITION AT TIME OF ENGAGEMENT & TRIM TO KEEP THE FORCES NEUTRAL. IF THE AIRCRAFT SLOWED, IT WOULD LOSE ALTITUDE & TRIM NOSE UP. RADAR DATA SHOWED THE ACFT STARTED TO SLOW, THEN DESCENDED FROM 8500 TO 8300 FT, THEN CLIMBED TO 8900 FT. THE ACFT THEN CAME DOWN VERY RAPIDLY TO 1700 FT PRIOR TO A RECOVERY. RPRTDLY, THE PLT DID NOT TEST THE AUTOPLT BEFORE TAKEOFF. .

Flight

Event TypeAccident
Event Time19:51 EST
Nearest Airport0nm N
Runway0
Flight Plan FiledNone
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftPiper PA-31-350
Tail NumberN40978
Aircraft CategoryAir
DamageSubstantial
OperatorFalcon Flight Center
Operating RulePart 91
Engines2
Engine TypeReciprocating
Engine DetailsLycoming · IO-540-J2B2 · Reciprocating · 350
Seats8

People & Injuries

Injury SummaryNo injuries (1 uninjured)
Fatal0
Serious0
Minor0
Uninjured1
Total1
Crew 1Age 26 · First Class

Conditions

ConditionsVMC
LightDark Night
WindCalm
Visibility20 sm
CeilingNone
Temperature / Dew Point0 C / 0 C
Altimeter0
Weather SourcePILO

Appendix: Source Data