NTSB Factual Report

HISTORY OF FLIGHT

On April 8, 2017, about 1256 eastern daylight time, a Piper PA-12, N3280M, was destroyed by impact and postcrash fire after takeoff from Orlando Sanford International Airport (SFB), Orlando, Florida. The airline transport pilot was fatally injured. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the local personal flight.

According to air traffic control audio information, the pilot received a takeoff clearance for runway 27L for closed traffic, which the pilot acknowledged. There were no further communications with the pilot.

Multiple witnesses stated that the airplane accelerated normally, lifted off, and immediately pitched up to a near vertical attitude. One witness stated, "it was like someone took the control yoke full aft." The witnesses reported that the airplane reached an altitude of about 100 ft, stalled, rolled to the right, and descended in a nose-down attitude to impact on the right side of runway 27L. A postimpact fire ensued that was extinguished by aircraft rescue and firefighting personnel on the airport. A witness recorded the flight on his mobile telephone. The video showed the airplane's takeoff roll, rotation, and initial climb and ended as the airplane pitched up to a nose-high attitude.

A mechanic who worked on the airplane with the pilot reported that the accident flight was the first flight following a 2-year restoration that included replacement of the wing and fuselage fabric, flight control cables, and electrical wiring. The mechanic stated that he was hesitant for the pilot to fly the airplane on the day of the accident. He wanted the pilot to do a high-speed taxi test first to check the tension on the cables and trim. The pilot stated he wanted to "hurry up and test fly it" as he had a friend visiting and wanted to take him flying in the airplane.

PERSONNEL INFORMATION

The pilot held an airline transport pilot certificate with airplane single- and multi-engine land ratings. He also held a flight instructor certificate with ratings for airplane single-engine, airplane multi-engine, and instrument airplane. His most recent Federal Aviation Administration (FAA) first-class airman medical certificate was issued on February 7, 2017, with the limitation, "must wear corrective lenses. " On the application form for this medical certificate, the pilot reported 25,000 total hours of flight experience and 400 hours in the previous 6 months. According to the pilot's logbooks, he had about 150 total flight hours in the accident airplane.

AIRCRAFT INFORMATION

The three-seat, high-wing, tail-wheel-equipped, fabric-covered airplane, serial number 12-2136, was manufactured in 1947. It was powered by a 115-horsepower Lycoming O-235-C1C engine, and equipped with a two-bladed, fixed pitch Sensenich propeller. Its most recent annual inspection was completed on March 25, 2017, at which time the airplane had 1,735.57 total flight hours.

METEOROLOGICAL INFORMATION

At 1253, the recorded weather at SFB included wind calm, visibility 10 statute miles, sky clear, temperature 22°C, dew point -3°C, and altimeter 30.11 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest inverted on a heading of about 170° magnetic in a grass area about 9 ft north of the north side of runway 27L, adjacent to the 1,000-ft markers. The nose of the airplane was crushed aft. The propeller remained attached to the engine, and it was located adjacent to a linear ground crater consistent with the dimensions of the propeller.

The empennage, fuselage, cockpit, and wings were consumed by postimpact fire. The engine exhibited significant thermal damage, and several of its accessories had separated during the impact sequence. The engine crankshaft was manually rotated, and continuity of the valve train was established from the crankshaft flange to the rear accessory section. Thumb compression was obtained on all four cylinders.

All flight control surfaces (ailerons, flaps, rudder, elevators, and trimmable horizontal stabilizer) remained attached to their respective attach points. The left and right aileron cables were continuous from the control stick to their respective bellcranks. The rudder cables were continuous from the foot pedals to the rudder bellcrank.

The elevator control cables were continuous from the upper and lower attach points on the elevator control horn to the forward and rear control sticks. Manipulation of the elevator control cables revealed that a nose-up input on either control stick resulted in a nose-down deflection of the elevator (instead of the proper nose-up deflection) and vice versa. Further examination revealed that the elevator cables were attached to the incorrect (opposite) attach points on the elevator control horn, which resulted in the reversal of elevator control inputs.

MEDICAL AND PATHOLOGICAL INFORMATION

The Office of the Medical Examiner, Leesburg, Florida, performed an autopsy of the pilot. The cause of death was listed as thermal and blunt force injuries.

The FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing. The results were negative for alcohol and drugs.

ADDITIONAL INFORMATION

During preflight inspection of a PA-12 (before engine start), a pilot can see the elevator's corresponding movements when the control stick is manipulated (either when standing by the open cockpit door or when seated in the front seat); likewise, a pilot standing on the ground and manipulating the elevator by hand can look forward and see the corresponding control stick movement. During a before takeoff check of the PA-12, a pilot can view the elevator from the pilot seat by turning around and looking back.

The National Transportation Safety Board (NTSB) issued Safety Alerts SA-041, "Pilots: Perform Advanced Preflight after Maintenance," and SA-042, "Mechanics: Prevent Misrigging Mistakes," in March 2015. That same month, the NTSB also released a Video Safety Alert, "Airplane Misrigging: Lessons Learned from a Close Call." The NTSB Safety Alerts and video, which inform general aviation pilots and mechanics about the circumstances of these types of accidents and provide information to help prevent such accidents, can be accessed from the NTSB's web site at www.ntsb.gov.

NTSB Probable Cause

The incorrect rigging of the elevator control cables, which resulted in a reversal of elevator control inputs applied by the pilot during the takeoff, an excessive nose-high pitch, and subsequent aerodynamic stall after takeoff. Also causal was the inadequate postmaintenance inspection and the pilot's inadequate preflight inspection and before takeoff check, which failed to detect the misrigging.