Aviation Investigation Final Report

Location: Myrtle Beach, South Carolina Accident Number: ERA21FA224

Date & Time: May 21, 2021, 18:14 Local Registration: N575BC

Aircraft: Piper PA-31P Aircraft Damage: Destroyed

Defining Event: Aircraft maintenance event Injuries: 1 Fatal

Flight Conducted Under: Part 91: General aviation - Personal

Analysis

The accident flight was the first flight after an annual inspection during which all flight control
surfaces were removed, repainted, and reinstalled. After departure, the pilot reported that he
needed to return to the runway. The airplane’s altitude fluctuated between 1,000 ft and 450 ft
mean sea level before radar contact was lost. Examination of the engines and propellers
revealed no mechanical failures or anomalies that would have precluded normal operation.
Examination of the airframe revealed that the elevator trim tabs were installed upside-down
and reversed, which would have resulted in the tabs moving opposite of the intended direction.
A command from the cockpit controls for nose-up trim would result in the tabs moving in the
airplane nose-down direction and vice versa. As found, both trim tabs were deflected trailing
edge up, which corresponded to a nose-down trim setting.

The mechanic who approved the airplane to be returned to service stated that, after the control
surfaces were reinstalled, he examined the primary flight controls for proper movement but did
not verify proper movement of the elevator trim tab. Although the control surfaces were tagged
with labels as they were removed, those labels likely did not remain attached throughout the
painting process, which contributed to their improper reinstallation.

The maintenance facility also maintained a different version of the accident airplane, which
was designed with the elevator trim tab control rod and control horn positioned on the bottom
of the trim tab. It is possible that the mechanic may have thought the trim tab installation on
the accident airplane was the same, which could explain why the mechanic inadvertently
installed the elevator trim tabs in reverse. Although the illustrated parts catalog (IPC) warned
in the introduction section that the IPC should not be used for rigging and installation
purposes, a figure on a subsequent page of the IPC incorrectly depicted the elevator trim tab
control horn positioned on the bottom side of the elevator trim tab. Had the mechanic referred
to this figure, it may have contributed to the incorrect installation of the trim tabs.

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It is likely that the pilot applied nose-up trim during takeoff, and subsequently experienced
nose-down trim forces due to the improper installation of the trim tab. After 2 minutes of
flight, the pilot was unable to maintain control of the airplane, possibly due to the unexpected
control forces, which resulted in a rapid descent and collision with terrain.

Toxicology testing detected ethanol in the pilot’s liver (0.225 and 0.078 gm/hg) and muscle
tissue (0.144 gm/hg). Another postmortem microbial product, propanol, was detected in his
liver tissue by one laboratory and in muscle tissue by a second laboratory. When consumed,
ethanol distributes quickly and uniformly to body tissues based on water content. One would
expect the concentrations in the two liver tissue samples to be similar and the concentrations
in liver and muscle tissue to be similar as well. Given the different ethanol tissue
concentrations, the state in which the body was recovered, and the presence of n-propanol in
liver and muscle tissue, it is likely that the identified ethanol was from sources other than
ingestion. Thus, the identified ethanol did not contribute to this accident.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The mechanic’s inadvertent installation of the elevator trim tabs in reverse, which resulted in
the pitch trim system operating opposite of the pilot’s input and the pilot’s subsequent loss of
control.

Findings
Aircraft Elevator tab control system - Incorrect service/maintenance
Personnel issues Repair - Maintenance personnel
Personnel issues Aircraft control - Pilot

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Factual Information

History of Flight
Approach-VFR pattern Sys/Comp malf/fail (non-power)
downwind
Prior to flight Aircraft maintenance event (Defining event)

On May 21, 2021, at 1814 eastern daylight time, a Piper PA-31P, N575BC, was destroyed when
it was involved in an accident near Myrtle Beach, South Carolina. The airline transport pilot
was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91
personal flight.

The accident flight was the airplane’s first flight following completion of an annual inspection.
Before the flight, the airplane was fueled with 167.5 gallons of 100 low lead aviation fuel.

The airplane departed Myrtle Beach International Airport (MYR), Myrtle Beach, South
Carolina, at 1812, with the intended destination of Grand Strand Airport (CRE), North Myrtle
Beach, South Carolina. According to automatic dependent surveillance-broadcast and air
traffic control (ATC) communications information, the pilot established contact with ATC and
reported that he was ready for departure from runway 18. He was instructed to fly runway
heading, climb to 1,700 ft mean sea level (msl), and was cleared for takeoff. Once airborne, the
controller instructed the pilot to turn left; however, the pilot stated that he needed to return to
runway 18. The controller instructed the pilot to enter a right closed traffic pattern at 1,500 ft
msl.

As the airplane continued to turn to the downwind leg of the traffic pattern, it reached an
altitude of about 1,000 ft mean sea level (msl). While on the downwind leg of the traffic
pattern, the airplane descended to 450 ft msl, climbed to 700 ft msl, and then again descended
to 475 ft msl before radar contact was lost. About 1 minute after the pilot requested to return to
the runway, the controller asked if any assistance was required, to which the pilot replied, “yes,
we’re in trouble.” There were no further radio communications from the pilot.

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 Pilot Information
Certificate: Airline transport; Commercial; Age: 60,Male
Flight instructor
Airplane Rating(s): Single-engine land; Single-engine Seat Occupied: Left
sea
Other Aircraft Rating(s): None Restraint Used: Unknown
Instrument Rating(s): Airplane Second Pilot Present: No
Instructor Rating(s): Airplane multi-engine; Airplane Toxicology Performed: Yes
single-engine
Medical Certification: Class 1 With waivers/limitations Last FAA Medical Exam: December 23, 2020
Occupational Pilot: Yes Last Flight Review or Equivalent:
Flight Time: 20000 hours (Total, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Piper Registration: N575BC
Model/Series: PA-31P Aircraft Category: Airplane
Year of Manufacture: 1977 Amateur Built:
Airworthiness Certificate: Normal Serial Number: 31P-7730004
Landing Gear Type: Retractable - Tricycle Seats: 8
Date/Type of Last May 19, 2021 Annual Certified Max Gross Wt.:
Inspection:
Time Since Last Inspection: Engines: 2 Reciprocating
Airframe Total Time: 4826.6 Hrs as of last Engine Manufacturer: Lycoming
inspection
ELT: Installed, activated, did not aid Engine Model/Series: TIGO-541-E1A
in locating accident
Registered Owner: On file Rated Power: 425 Horsepower
Operator: On file Operating Certificate(s) None
Held:

The airplane’s most recent annual inspection was completed on May 19, 2021. Maintenance
performed at that time included removing, repainting, and reinstalling the primary and
secondary flight control surfaces.

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 Meteorological Information and Flight Plan
Conditions at Accident Site: Visual (VMC) Condition of Light: Day
Observation Facility, Elevation: MYR,25 ft msl Distance from Accident Site: 2 Nautical Miles
Observation Time: 17:56 Local Direction from Accident Site: 91°
Lowest Cloud Condition: Clear Visibility 10 miles
Lowest Ceiling: None Visibility (RVR):
Wind Speed/Gusts: 10 knots / Turbulence Type /
Forecast/Actual:
Wind Direction: 110° Turbulence Severity /
Forecast/Actual:
Altimeter Setting: 30.4 inches Hg Temperature/Dew Point: 24°C / 18°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Myrtle Beach, SC (MYR) Type of Flight Plan Filed:
Destination: North Myrtle Beach, SC Type of Clearance: Unknown
(CRE)
Departure Time: 18:12 Local Type of Airspace: Class C

Airport Information
Airport: MYRTLE BEACH INTL MYR Runway Surface Type: Asphalt
Airport Elevation: 25 ft msl Runway Surface Condition: Dry
Runway Used: 18/36 IFR Approach: None
Runway Length/Width: 9503 ft / 150 ft VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Fatal Aircraft Damage: Destroyed
Passenger N/A Aircraft Fire: On-ground
Injuries:
Ground Injuries: N/A Aircraft Explosion: None
Total Injuries: 1 Fatal Latitude, 33.685597,-78.968609
Longitude:

The airplane impacted in a field about 0.1 mile from the last radar return, at an elevation of
20 ft. A postimpact fire ensued, and the debris field was about 400 ft long by 150 ft wide. All
major components of the airplane were in the vicinity of the main wreckage. Each engine came
to rest in about a 5-ft crater and remained attached to the fuselage.

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The left engine crankcase was impact damaged in multiple locations. The gearbox was impact
separated. All valve covers remained intact and attached to the cylinders. The valve covers were
removed, and no anomalies were noted. Examination with a lighted borescope revealed
crankshaft and camshaft continuity and no anomalies of the cylinders. All engine accessories
were impact separated and fragmented. The left engine turbocharger was impact separated and
would bind when rotated by hand; scoring was noted on the casing.

The right engine crankcase was impact damaged in multiple locations. All valve covers
remained intact and attached to the cylinders. The valve covers were removed and no
anomalies were noted. Examination with a lighted borescope revealed crankshaft and camshaft
continuity and no anomalies of the cylinders. All engine accessories were impact separated and
fragmented. The oil suction screen was removed and was not occluded. The right engine
turbocharger was impact separated and would bind when rotated by hand.

The left propeller was impact separated from the engine. Two of the three blades were
separated from the hub. All blades exhibited polishing. One blade was bent forward, one
exhibited tip curling, and the last blade was bent aft. The blade that was bent aft remained
attached to the propeller hub.

The right propeller was impact separated from the right engine. Two of the three blades were
impact separated from the hub. All blades exhibited polishing. One blade was bent forward,
one blade was bent aft, and one blade remained straight. The straight blade remained attached
to the propeller hub.

Flight control cable continuity was established from all flight control surfaces to the cockpit
through multiple overload breaks in the cables. The wings and fuselage were largely consumed
by fire. The remaining skin and structure exhibited accordion-like impact damage that was
symmetrical on both wings. The landing gear was in the extended position. The flaps were in
the retracted position. The empennage was separated from the fuselage and located about 50 ft
from the main wreckage. The top section of the vertical stabilizer and the rudder were impact-
crushed downward. The elevator remained attached to the right horizontal stabilizer. The right
trim tab remained attached to the right elevator, was deflected trailing edge up, but was impact
separated from the control rod. The left trim tab remained attached to the left elevator, the
connecting rod remained attached to the flight controls, and it was deflected trailing edge up.

Further examination of the elevator trim tabs revealed that both were installed upside-down
and reversed (the left tab was installed on the right elevator and the right tab on the left
elevator). As a result, the control horns on both trim tabs and their respective control rods,
which should have been located on the top side of the trim tabs above the tab’s hinge line, were
instead located on the bottom side of the tabs below the tab’s hinge line. This installation
resulted in a reversal of the direction of the trim tabs’ movements; a command of nose-up trim
from the cockpit controls would incorrectly move the trim tabs in the nose-down direction, and
vice versa.

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 Medical and Pathological Information

Toxicology testing performed for the Department of Pathology and Laboratory Medicine’s
office detected ethanol at 0.225 milligrams per hectogram (mg/hg) and isopropanol in the
pilot’s liver tissue. Caffeine was also detected in his liver tissue. Toxicology testing performed
by the FAA Forensic Sciences Laboratory detected ethanol in the pilot’s liver tissue at 0.078
gm/hg and in his muscle tissue at 0.144 gm/hg; n-propanol was detected in muscle tissue. The
non-sedating fever and pain medication acetaminophen was detected in his liver and muscle
tissue.

Ethanol is a social drug commonly consumed by drinking beer, wine, or liquor. It acts as a
central nervous system depressant; it impairs judgment, psychomotor functioning, and
vigilance. Ethanol is water soluble, and after absorption it quickly and uniformly distributes
throughout the body’s tissues and fluids. The distribution pattern parallels water content and
blood supply of the tissue. Ethanol can be produced after death by microbial activity;
sometimes in conjunction with other alcohols, such as propanol. Extensive trauma increases
the spread of bacteria and raises the risk of ethanol production after death.

Additional Information

Maintenance Facility

According to the director of maintenance, during the annual inspection, corrosion was noted
on the flight control surfaces, and the surfaces were removed from the airplane for corrosion
removal, repair, and repainting. When the primary and secondary flight control surfaces were
removed, they were tagged; however, during the process of repainting, because of the corrosive
solutions the tag was separated from the control surface.

After the maintenance was performed on the airplane, the director of maintenance had another
mechanic sit in the airplane and exercise the controls while he verified the primary flight
control movement to ensure that they were installed properly. He did not check the elevator
trim tab movement for proper installation. The director of maintenance, who was a mechanic
with inspection authorization, approved the airplane for return to service.

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The director of maintenance further stated that he also maintained a non-pressurized Piper
PA-31 (the accident airplane was the pressurized version). The non-pressurized PA-31 was
equipped with only one elevator trim tab located on the right side of the elevator, and the
control horn and control rod were located on the bottom side of the trim tab.

PA-31P Illustrated Parts Catalog

According to the Piper PA-31P illustrated parts catalog, the Elevator Assembly figure
incorrectly depicted the control horn on the bottom of the trim tab. (see Figure 1.) The
illustrated parts catalog also noted in the Introduction section that, “UNDER NO
CIRCUMSTANCES SHALL THIS CATALOG BE USED FOR RIGGING AND INSTALLATION
PURPOSES.”

Figure 1. Excerpt from Illustrated Parts Catalog showing the control horn located on the
bottom side of the elevator trim tab.

PA-31P Maintenance Manual

According to the Piper PA-31P maintenance manual, the elevator and elevator trim control
figures correctly depicted that the control rod attached to the control horn as located on the top
of the elevator trim tab. The instructions to install the elevator trim tab indicated to, “refer to
figure 4-5.” Figure 2 is an excerpt from Figure 4-5 in the maintenance manual.

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Figure 2. Excerpt from Airplane Maintenance Manual showing the trim tab hinge, with the
control horn, and control rod located on the top side of the elevator trim tab.

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 Administrative Information
Investigator In Charge (IIC): Kemner, Heidi
Additional Participating James Jackson; FAA/FSDO; Columbia, SC
Persons: Damian Galbraith; Piper Aircraft; Vero Beach, FL
Troy Helgeson; Lycoming Engines; Williamsport, PA
Original Publish Date: August 12, 2022
Last Revision Date:
Investigation Class: Class 3
Note:
Investigation Docket: https://data.ntsb.gov/Docket?ProjectID=103126

The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with
investigating every civil aviation accident in the United States and significant events in other modes of transportation—
railroad, transit, highway, marine, pipeline, and commercial space. We determine the probable causes of the accidents
and events we investigate, and issue safety recommendations aimed at preventing future occurrences. In addition, we
conduct transportation safety research studies and offer information and other assistance to family members and
survivors for each accident or event we investigate. We also serve as the appellate authority for enforcement actions
involving aviation and mariner certificates issued by the Federal Aviation Administration (FAA) and US Coast Guard, and
we adjudicate appeals of civil penalty actions taken by the FAA.

The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation,
“accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties … and are
not conducted for the purpose of determining the rights or liabilities of any person” (Title 49 Code of Federal Regulations
section 831.4). Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve
transportation safety by investigating accidents and incidents and issuing safety recommendations. In addition,
statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a
civil action for damages resulting from a matter mentioned in the report (Title 49 United States Code section 1154(b)). A
factual report that may be admissible under 49 United States Code section 1154(b) is available here.

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