NTSB Factual Report

HISTORY OF FLIGHT

On November 7, 2001, at 1118 eastern standard time, a Cessna 310Q, N7648Q, collided with trees and subsequently the ground in a residential area following a loss of control after takeoff from the Smith Reynolds Airport in Winston Salem, North Carolina. The airplane was registered to Quality Aircraft Sales LLC, and operated by the private pilot under the provisions of Title 14 CFR Part 91, and instrument flight rules (IFR). Visual meteorological conditions prevailed and an IFR flight plan was filed. The pilot was fatally injured and the airplane was destroyed. The flight was originating at the time of the accident.

According to Winston Salem Tower Air Traffic Control (ATC) Transcripts, the pilot departed runway 22 at the Smith Reynolds Airport at 1112, enroute to Centerville, Tennessee. At 1113, the pilot reported that he was returning with a problem. At 1116, the pilot reported that he was experiencing "a lot of down pressure on the yoke". At 1117, the pilot requested runway 04, the controller cleared the pilot for a visual approach to runway 04 but received no response. At 1118, Winston Salem Tower reported that radar contact was lost. At 1120, Windston Salem Tower received a report from the local fire department that they had received a call that there was an airplane crash west of the airport.

PILOT INFORMATION

The pilot held a private pilot certificate with ratings and limitations for airplane single and multi-engine land and instrument airplane's. At the time of the accident the pilot had accumulated 2,825 hours in all aircraft, 2,195 hours in multi-engine airplanes and 34 hours in the Cessna 310Q. The pilot's most recent third class medical certificate was issued on May 1, 2000, with no waivers or limitations.

AIRCRAFT INFORMATION

The Cessna 310Q, S/N 310Q0427, was manufactured and certificated in 1971. It was a six seat, twin engine airplane with tricycle retractable landing gear. Federal Aviation Administration (FAA) records revealed that the airplane was registered to the current owners on December 23, 1971. A review of the airplane's maintenance logbook found that on April 1, 2001, the airplane's total time was 3,615 hours. On that date, the airplane was painted, the interior was refurbished and the airplane underwent a 100 hour inspection. According to the logbook entry, all flight controls were removed, stripped, repainted and balanced prior to being reinstalled on the airplane. At the time of the accident, the airplane had accumulated an additional 35 hours for a total time of 3,650 hours.

METEOROLOGICAL INFORMATION

Weather at the time of the accident was reported by witnesses as clear. Greensboro Flight Service Station was reporting weather at 1054, as winds 320 at 4 knots, visibility 10 statute miles, sky clear, temperature 19 celcius, dew point minus 1 celcius, altimeter 30.29. Greensboro provided a special weather report at 1136, which reported winds as calm, visibility 10 statute miles, sky clear, temperature 21 celcius, dew point 1 celcius, altimeter 30.28.

WRECKAGE EXAMINATION

Examination of the accident site found that the wreckage debris was located in a heavily wooded residential area. The crash debris line extended through a wooded area on a heading of 055 degrees magnetic. The pitch angle from the first tree contact to the ground crater was approximately 60 degrees, and the roll angle was approximately 55 degrees left wing low. The left wing tip tank was near the first ground contact location. A piece of the cabin overhead was observed embedded in a tree to the left of the crash debris line. There was no fire.

The aileron flight control system continuity could not be established due to impact damage. All aileron control cables, which were observed, were separated in a tension overload type separation. The aileron cables were attached over the sprocket in the control column and were continuous out to the right wing. The cables to the left wing were observed separated. The aileron trim tab was observed separated and loose in the wreckage distribution path. The rudder control cables were observed attached to the rudder and were continuous to the rudder pedals. The rudder trim control cables were observed attached over the sprocket and were continuous up to the cockpit area. All of the attachments observed in the flight control system were bolts with castellated nuts and cotter pins.

The elevator trim tab actuator to rod end attachment bolt and castellated nut were not found in the wreckage. No damage was observed to the screw jack rod end. There was also no damage to the attachment holes in the trim tab actuator rod end. Damage was observed to the elevator forward spar and inside leading edge skin, which matched the actuator rod end. The elevator flight control cables were attached to the bell cranks at both ends. The forward elevator actuation tube rod end at the bell crank and the aft elevator control tube were observed separated. The rod remained attached to the left elevator torque tube. The elevator trim cables remained attached to the trim tab actuator and were observed attached to the trim wheel in the cockpit area. The elevator trim screw jack was observed past the full nose up trim position. All cabin seats were destroyed in the accident sequence, and all seat belts had separated from their attachment points during the impact sequence.

Both main fuel tanks, tip tanks, and the auxiliary fuel tanks (wing bladders) were ruptured at the accident site. All of the fuel lines were separated from the engine. Both of the engine driven fuel pumps were removed from the engines and their drive couplings were intact.

There was extensive damage to both engines. This damage precluded a determination of continuity of either of the engines. Both engines were separated from the airframe. Both propellers were separated from the engines. All propeller blades remained attached to their respective propeller hubs. There was significant twisting and leading edge damage to all of the propeller blades

Examination of the left engine found the oil sump crushed, the number 2, 4, and 6 cylinders were cracked, the exhaust pipes were crushed, and the number 2, 4, 5, and 6, rocker covers were missing. The fuel pump was removed and the drive shaft was intact. The oil sump was removed and the camshaft and gears were intact. All connecting rods were attached, the crankshaft was intact, all counterweights were on their respective pins and the oil screen was free of contaminants. The spark plugs were gapped in accordance with manufacturers specifications. The crankshaft was broken at the flange. It was not possible to rotate the engine due to cylinder damage. The following items were found separated from the engine: the fuel control unit, vacuum pump, alternator, oil cooler, starter, both magnetos, intake tubes on the number 2, 4, and 6 cylinders and the propeller governor. The overall condition and visual examination of the engine and parts, did not reveal discrepancies which would have precluded normal operation prior to impact.

Examination of the right engine found that the camshaft gear was bent, and the internal engine components would not rotate. The oil sump was removed and the camshaft was intact, the crankshaft was also intact, all connecting rods were attached, and the counterweights were all on their respective pins. The fuel pump was removed and the drive shaft was intact. The crankcase was broken in the forward lower area. The oil sump was peeled back, and the exhaust pipes were crushed. The propeller bolts were pulled from the hub. The following parts were separated from the engine as a result of impact damage; the number 5 rocker cover, intake pipes, prop governor, started, vacuum pump, both magnetos, alternator, tachometer, generator, oil cooler and the fuel control unit. The overall condition and visual examination of the engine and parts did not reveal any discrepancies which would have precluded normal operation prior to impact.

MEDICAL/PATHOLOGICAL INFORMATION

An autopsy examination of the pilot was conducted by the Office of the Chief Medical Examiner, Chapel Hill, North Carolina. The autopsy examination established the manner of death as; Accident, and the cause of death as Multiple Blunt Trauma.

A toxicological examination was performed by the Federal Aviation Administration Civil Aeromedical Institute, in Oklahoma City, Oklahoma. The toxicology report on the pilot indicated that there were no Ethanol or Drugs found in the muscle or liver samples. Tests for Carbon Monoxide and Cyanide were not performed.

TESTS AND RESEARCH INFORMATION

Based on the pilot's statement during the final minutes of his flight, and the on-scene examination of the elevator system, the following components were sent to the Material and Process Engineering Laboratory at the Cessna Aircraft Company in Wichita, Kansas, for further examination; trim tab assembly, push-pull rod clevis and a section of the elevator. The examinations of the above components were witnessed by a representative of the Federal Aviation Administration.

Examination of the forward trim tab push-pull rod clevis revealed that the attaching bolt was missing for an undetermined time prior to the accident, and that the damage to the trim tab push-pull rod showed that it was in the full up position (elevator full down) at the time of impact. Additionally, the geometry of the trim tab push-pull rod would have allow it to pass behind the forward elevator spar. The trim tab actuator to push rod bolt were missing and the rod jammed behind the forward spar of the elevator at the time of the mishap. (See attachment for complete metallurgical report).

ADDITIONAL INFORMATION

The wreckage was released to the owners representative on November 25, 2001, Quality Aircraft Leasing LLC.

NTSB Probable Cause

Improper installation of the elevator trim tab control rod by maintenance personnel which allowed the control rod to disconnect and jam in the full up position (elevator full down) while in-flight. This resulted in a loss of directional control and subsequent impact with trees and terrain.