N813SP

HISTORY OF FLIGHT

On August 6, 2001, about 1145 Alaska daylight time, a Cessna 172S airplane, N813SP, sustained substantial damage during a precautionary landing at the Quartz Creek Airport, located about 3 miles east of Cooper Landing, Alaska. The airplane was being operated as a visual flight rules (VFR) local area personal flight when the accident occurred. The airplane was registered to Av Alaska Inc., Anchorage, Alaska, and operated by the pilot. The private certificated pilot and one passenger received serious injuries. Two other passengers were not injured. Visual meteorological conditions prevailed. A VFR flight plan was filed. The flight originated at the Ted Stevens Anchorage International Airport about 1100.

According to information provided by an Alaska State Trooper, and information provided by a witness at the Quartz Creek Airport, the accident airplane was observed to touch down about mid-length on runway 21 and bounce several times. The airplane then collided with trees beyond the departure end of the runway, and came to rest next to a boat launch ramp in an adjacent campground. At the accident scene, the airplane was resting upright on its main landing gear, but nose down, with the nose wheel strut displaced forward, under the engine. The engine cowling was torn off the fuselage. The right wing separated from the fuselage at its rear attach point, and the wing was displaced forward from the fuselage.

In a telephone interview with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on August 10, the pilot reported that during the flight, the airplane suddenly began climbing. She said she used the manual trim wheel to trim the airplane nose down, but the airplane still pitched upward. She pushed forward on the control yoke in an attempt to counter the upward pitch. She said she did not know if the autopilot was on or off, but she did not consciously select or use the autopilot, and she said she did not know if the airplane was equipped with electric trim. She headed for the Quartz Creek airport, and bounced twice on the runway. The wheels collided with trees at the end of the runway.

During an in-person interview with the NTSB IIC on August 15, the pilot reported that after departing Anchorage, the airplane was in cruise flight about 3,000 feet msl near Kenai Lake. During the flight, the airplane suddenly began to pitch upward, climbing about 600 feet per minute. The pilot said she pushed forward on the control yoke to return to 3,000 feet msl, and noticed the trim wheel moving in a nose up direction. The pilot began to exert forward pressure on the control yoke to keep the airplane from climbing, and she said she was concerned that the airplane might stall. She asked her front seat passenger to help push forward on the control yoke. The pilot made a "mayday" call on the airplane radio, and decided to make an emergency landing at the Quartz Creek airport. The pilot said she turned onto about a one mile final approach to runway 21, but was either going too fast, or the runway was too short. She said she saw the end of the runway approaching, and added full throttle to begin a go-around. The airplane collided with trees at the departure end of runway 21. She said she had lowered the flaps for landing, but raised the flaps for the go-around.

The pilot said she did not remember any annunciator lights on the instrument panel, but during the emergency, she did remember seeing 7000 displayed in a box located above the transponder. The pilot said she used the radio transmit button on the left side of the pilot's control yoke, but did not use any other switches on the yoke. She reiterated that she was not aware the airplane had electric trim. The pilot said her front seat passenger is not a pilot, and did not touch any items on the control panel.

During an interview with the NTSB IIC, the front seat passenger reported that during their flight, the pilot suddenly told everyone to be quiet. The pilot was having trouble controlling the pitch of the airplane, and appeared to be attempting to trim the airplane by the use of a trim wheel. She was asked by the pilot to help push on the control yoke. She remember seeing a small landing strip in the area, but did not remember anything else until being placed in an ambulance.

PERSONNEL INFORMATION

The pilot holds a private pilot certificate with an airplane single-engine land rating. The most recent third-class medical certificate was issued to the pilot on December 15, 2000, and contained the limitation that the pilot must have available glasses for near vision.

According to the information contained in the Pilot/Operator Report (NTSB Form 6120.1/2) submitted by the pilot, the pilot's total aeronautical experience consists of about 230 hours, of which 220 were accrued in the accident airplane make and model. In the preceding 90 and 30 days prior to the accident, the report lists a total of 10.5 and zero hours, respectively.

The pilot reported she utilized the accident airplane for several instrument training flights and for personal use, and had accrued about 6 hours in the accident airplane (Cessna 172S). She said she was familiar with the electronic HSI and the moving map on the multifunction display. When she was receiving instrument flight training from an instrument instructor, she said she did not use the autopilot system, and was not provided with any familiarization with its function or controls. She said she was not aware the airplane had an electric trim system. The pilot said she was not provided with any training or a check out on the autopilot or electric trim system from the operator. She said that during personal flights, she did not intend to use the autopilot system, and had not familiarized herself with its functions or controls.

AIRCRAFT INFORMATION

The airplane and engine had accumulated a total time in service of 333.4 hours since new. The airplane was maintained on an approved airworthiness inspection program (AAIP). The most recent inspection was accomplished on July 25, 2001, 38.2 hours before the accident.

The operator added the airplane to its fleet of rental airplanes in February, 2001. The airplane was equipped with a Honeywell KAP 140 two axis autopilot with altitude preselect, a Bendix/King transponder, dual Bendix/King KX 155A Nav/Comm radios, a Honeywell KLN 94 GPS navigation computer. The accident airplane was used for rental customers, and as a training airplane for students.

In March, 2001, additional equipment was installed in the airplane, including a Sandel Avionics SN 3308 Navigational Display, and a UPS Aviation Technologies, MX20 multifunction display as part of an FAA Capstone navigation/terrain and radar tracking demonstration project. The airplane's center radio/navigation stack was modified from its standard instrument panel installation to accommodate the installation of the multifunction display at the top of the center panel radio stack. The Honeywell KAP 140 autopilot computer, normally positioned at the bottom of the radio stack, and the airplane's transponder, were both moved to the right of the center stack. The autopilot was positioned in the center of the right side of the instrument panel, above the transponder, both in front of the right seat position.

The KAP 140 autopilot system consists of a computer/controller, interconnected to the GPS and navigation system displays, pitch and roll actuator servos, control yoke switches, and an electrical system, pull-type, circuit breaker. It provides an autotrim feature during autopilot operation, and manual electric trim when the autopilot is not engaged. The airplane also retains a manual trim wheel. The features of the autopilot system include a vertical speed mode, altitude hold, wing level, heading select, approach, ILS coupling to a localizer and glideslope, backcourse mode, altitude alert and altitude preselect. The electric trim system is designed to be fail safe for any single in-flight trim malfunction. Trim faults are visually and aurally annunciated. A lockout device prevents autopilot or electric trim engagement until the system has successfully passed a preflight self test. An automatic preflight self test begins with initial power application to the avionics electrical bus.

The left side of the pilot's control yoke contains a radio transmit button on the back side of the yoke. The front side of the yoke contains an autopilot disconnect button, and split manual electric trim switches, both of which need to be activated simultaneously to energize the electric trim.

The auto pilot system may be activated by pushing the autopilot engage/disengage button, heading select button, or the altitude hold button.

The autopilot system will disengage if an electrical power failure occurs, an internal autopilot system failure, pitch accelerations in excess of plus 1.4g or less than plus .6g (if produced by a servo runaway, not by maneuvering), a turn coordinator failure, activation of the roll, or pitch axis annunciator, activation of the A/P Disconnect/Trim switch on the control yoke, pulling off the autopilot system electrical circuit breaker, or turning off the avionics master or airplane electrical master switch.

Normal and emergency procedures for the autopilot system are listed in Supplement 15 of the airplane's information manual. The emergency procedures section of Supplement 15 that address autopilot, autopilot trim, or electric trim malfunctions, states, in part: Airplane control wheel - grasp firmly and regain aircraft control, and simultaneously press and hold the A/P DISC/Trim INT switch on the control yoke; re-trim manually as needed; autopilot circuit breaker - pull. The avionics master switch may be used as an alternate means of removing all electric power from the autopilot and electric trim systems.

Supplement 15 contains several warnings, including: ...