Veteran pilot dies in crash after failing to remove flight control lock

The pilot of the SIAI-MARCHETTI SM-1019B contacted ground control at the airport in Lewiston, Idaho, requesting taxi clearance from the FBO ramp for a Runway 12 departure at the taxiway D intersection (located about 900 feet from the FBO hangar where the airplane was stored).

The controller instructed the pilot to taxi via Taxiway D. While still on the ground frequency, the pilot asked if he was cleared for takeoff, and about 20 seconds later (after communicating with another aircraft) the controller replied and cleared the pilot for takeoff from Runway 12 at Taxiway D. The pilot responded, and the controller requested that he switch to the tower control frequency.

After apologizing, the pilot contacted the tower controller. The tower controller confirmed contact with the pilot and cleared the airplane for takeoff. At 11:51:41, the pilot replied, “for takeoff,” and 36 seconds later, at 11:52:17, expletives were heard.

Relatives and acquaintances of the pilot who listened to the audio recordings of the ATC communications stated that the expletives came from the pilot.

According to the pilot’s wife, he planned to fly to Hungry Ridge Ranch Airport (37ID) in Grangeville, Idaho, where he owned a residence. She stated that the pilot was in no hurry, and there was no time-sensitive reason for him to be at the destination.

Airport security video cameras located at the main passenger terminal captured the airplane positioned on Runway 12 at the intersection of taxiway D before takeoff. The airplane began the takeoff roll and continued about 400 feet down the runway before taking off in a three-point departure configuration.

The airplane pitched nose-up to about 45° while climbing to an altitude of about 80 feet above ground level, after which it rolled 90° to the left as the nose dropped. The airplane continued to roll left while descending and hit the ground in a nose-down, left-wing-low attitude between Runway 12 and Taxiway C, about 970 feet beyond where the takeoff roll began.

A post-impact fire ensued. The pilot died in the crash.

Witnesses at the airport described the airplane taking off normally before it aggressively pitched up and rolled left.

The pilot was a retired naval aviator, and current air show performer, with extensive flight experience in a broad range of aircraft. He held a commercial pilot certificate with ratings for airplane single-engine land and sea, airplane multi-engine land, and instrument airplane. At the time of his last medical examination, on Oct. 29, 2020, he reported 6,500 total hours of civilian flight experience.

The pilot purchased the airplane on April 21, 2021, and it was delivered to him in June by a friend, who was also a flight instructor. The instructor flew with the pilot for the first flight after delivery, during which they performed slow flight, stalls, steep turns, and multiple stop-and-go landings.

The instructor stated that the pilot demonstrated proficiency in the operation of the airplane, and at no time did he need to take the controls.

The instructor stated that, before their first flight, the pilot performed a very thorough and detailed walk-around, lasting approximately 90 minutes. He was particularly impressed with his “exemplary” checklist discipline, both during that flight, and when he had flown with the pilot previously.

During the preflight, he observed the pilot perform a full check of the flight controls to verify proper movement and operation. They discussed the control lock operation, and the pilot stated that it was very similar to the lock used on other airplanes he had owned and flown.

The airplane was equipped with a flight control locking system that comprised a pivoting, U-shaped control lock tube mounted permanently to the rudder pedal assembly, and a forward-facing locking arm and pin assembly mounted to the control stick. To engage the system, and lock the flight controls, the control lock is raised to the locking arm, where it engages with a pin to keep the control stick secure.

For flight, the control lock is lifted from the pin, and then pivots to the floor, where it is secured in place with a retainer clip near the base of the control stick. The control lock immobilizes the aileron and elevator controls and holds the rudder in the neutral position, but still allows for near-full movement of the rudder and tailwheel via the rudder pedals.

Varying accounts indicated that the pilot had flown the airplane about 20 times since purchase. The pilot’s wife had flown with him to KLWS earlier in the day in their other airplane. She told investigators she left him at the airport at 11:10, at which time the accident airplane was still in the hangar.

She stated that normally he would perform preflight checks after the airplane had been pulled out of the hangar, and that he was methodical and slow. She expressed surprise that he could have performed all his checks and still departed by the accident time.

The general manager for the FBO next to the hangar where the pilot stored his airplane stated that he had known the pilot for many years, and that he routinely observed him perform an engine run-up at the approach end of the runway before takeoff in all the airplanes he flew. He stated that he had never seen the pilot perform an intersection takeoff from midfield, and that the pilot’s preflight inspections took a very long time.

Examination of a similar airplane confirmed that, with the control lock engaged, although the ailerons and elevators were completely locked, the rudder and tailwheel could still be moved to near full travel, so that the airplane could be maneuvered almost completely unhindered while taxiing. Although the control lock is painted red, the pilot’s view of the lock in the engaged position is such that the lock is viewed at its narrowest profile, directly down its length.

Another 1019 series airplane owner relayed his experience with the flight control lock. He stated that, on one occasion, he had planned a local flight with a passenger in the back seat and became distracted and forgot to remove the flight control lock before flight. He was able to taxi for departure, still unaware that the lock was in place, and became distracted during the pre-takeoff checks because he was talking to the passenger. He stated that he was able to complete the initial stages of takeoff with the control lock engaged, and once he realized, he had to struggle to remove the lock due to the forces on the control stick during takeoff. After a few seconds he was able to free it, and the flight progressed uneventfully.

The pilot’s friend, who had delivered the airplane, stated that you could easily get into the airplane with the control lock engaged. He further stated that, like most tailwheel-equipped airplanes, heavy differential braking was required to steer the airplane, and only limited rudder movement was required.

Following the accident, he performed a series of checks in a similar airplane with the control lock attached. He determined that the airplane could be taxied uninhibited with the control lock engaged. With the control lock engaged and the airplane parked, he could not remove it with reasonable force if there was any control pressure on the stick, because it appeared to hang up on the lock pin until he released pressure.

The high resolution of the airport security video cameras and the proximity of the airplane to their location allowed for a relatively accurate estimation of the deflections of the flight control surfaces during the takeoff. Review of the footage revealed that the deflections of the elevator and ailerons were either zero or so small that they could not be seen. The airplane’s flaps were identified in an extended position.

When investigators examined the airplane’s wreckage, they found the flight control lock in the front seat connected to the rudder pedal assembly. The cabin floor forward of the control stick base, which would have been occupied by the 14-inch-long control lock when not in use, was compressed aft such that the base of the control stick was 4 inches away from the control lock pivots on the rudder pedal assembly. The control lock floor retainer clip, which would have been used to lock the control lock to the floor for flight, was undamaged.

The locking arm and pin assembly remained attached to the control stick and was undamaged, but had rotated 90° to the right of its original position. There was no evidence of contact between the locking arm and pin assembly with any components or structure in the footwell or instrument panel.

Probable Cause: The pilot’s failure to remove the flight control lock before departure, which resulted in a loss of airplane control and impact with terrain. Contributing to the accident was his failure to perform an adequate preflight inspection and flight control check before takeoff.

NTSB Identification: 103534

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This July 2021 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.