FlarePath

What happened

NTSB summary, verbatim

The pilot contacted air traffic control and requested clearance to taxi for departure approximately an hour after the scheduled departure time. About 4 minutes later, the flight was cleared for takeoff. A witness observed the airplane as it taxied, and found it strange that the airplane did not stop and "rev up" its engines before takeoff. Instead, the airplane taxied onto the runway and proceeded with the takeoff without stopping. The airplane took off quickly, within 100 yards of beginning the takeoff roll, became airborne, and entered a steep left bank. The bank steepened, and the airplane descended and impacted the ground. Postaccident examination of the wreckage revealed that the pilot's four-point restraint was not fastened and that at least a portion of the cockpit flight control lock remained installed on the control column. One of the pretakeoff checklist items was, "Flight controls - Unlocked - Full travel." The airplane was not equipped with a control lock design, which, according to the airframe manufacturer's previously issued service bulletins, would "minimize the possibility of the aircraft becoming airborne when take off is attempted with flight control locks inadvertently installed." In 1990, Transport Canada issued an airworthiness directive to ensure mandatory compliance with the service bulletins; however, the Federal Aviation Administration did not follow with a similar airworthiness directive until after the accident.

Photographs

1the aircraft, and what the investigators found

The aircraft before the accident

Probable cause

the Board's determination

The pilot's failure to remove the flight control lock prior to takeoff. Contributing to the accident was the Federal Aviation Administration's failure to issue an airworthiness directive making the manufacturer's previously-issued flight control lock service bulletins mandatory.

Occurrence sequence

2 stepsNTSB coding · CICTT taxonomy

1 · Takeoff
Loss of control in flight
defining event
2 · Uncontrolled descent
Collision with terr/obj (non-CFIT)

Findings

3 causal · 0 contributing

CAUSE
Personnel issues › Task performance › Use of equip/info › Use of equip/system — Pilot
CAUSE
Organizational issues › Development › Design › Policy/procedure development — FAA/Regulator
CAUSE
Aircraft › Aircraft systems › Flight control system › Gust lock or damper — Incorrect use/operation

NTSB analysis

from the final report

The pilot contacted air traffic control and requested clearance to taxi for departure approximately an hour after the scheduled departure time. About 4 minutes later, the flight was cleared for takeoff. A witness observed the airplane as it taxied, and found it strange that the airplane did not stop and "rev up" its engines before takeoff. Instead, the airplane taxied onto the runway and proceeded with the takeoff without stopping. The airplane took off quickly, within 100 yards of beginning the takeoff roll, became airborne, and entered a steep left bank. The bank steepened, and the airplane descended and impacted the ground. Postaccident examination of the wreckage revealed that the pilot's four-point restraint was not fastened and that at least a portion of the cockpit flight control lock remained installed on the control column. One of the pretakeoff checklist items was, "Flight controls - Unlocked - Full travel." The airplane was not equipped with a control lock design, which, according to the airframe manufacturer's previously issued service bulletins, would "minimize the possibility of the aircraft becoming airborne when take off is attempted with flight control locks inadvertently installed." In 1990, Transport Canada issued an airworthiness directive to ensure mandatory compliance with the service bulletins; however, the Federal Aviation Administration did not follow with a similar airworthiness directive until after the accident.