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WPR17IA086 · Beech A36TC

10 Apr 2017 · Livermore, CA, United States

Beech A36TC · Incident on approach

From Tracy Municipal Airport (TCY) to Livermore Municipal Airport (LVK)

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Event

NTSB case
WPR17IA086
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Incident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
0 · all aircraft and ground
Ground fatalities
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
General aviation
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Visual Meteorological Cond

Beech A36TC

Aircraft type
Beechcraft 36
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N755R
Operator
Unknown
Onboard fatalities
Unknown
Route
From Tracy Municipal Airport (TCY), Tracy, CATo Livermore Municipal Airport (LVK), Livermore, CA
Aircraft age
About 37 years (built 1980)
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 91: General Aviation
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Approach
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Unknown or undetermined
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Minor

Cause areas

  • Aircraft › Aircraft systems
  • Environmental issues › Task environment
  • Personnel issues › Action/decision

Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.

NTSB narrative

After performing a series of uneventful landings in the single-engine airplane at a local airport, the pilot flew a return leg with the autopilot engaged. As he approached the airport, he disengaged the autopilot using the autopilot disconnect button on the control wheel. The airplane then immediately pitched up aggressively with an immediate loss of airspeed such that the pilot feared the airplane was about to stall. He applied full forward pressure on the control wheel, and the airplane pitched almost directly nose down and began to quickly build airspeed. He then reduced the control wheel pressure, and the airplane pitched back up again. He was able to maintain an approximate level attitude with full forward control wheel pressure, although the control forces were so great that he needed to use both hands and his knee to keep the control wheel forward.

During the event, the pilot reportedly attempted to adjust pitch with the trim wheel, but it was jammed. He also attempted to disengage the autopilot by pulling its circuit breaker; however, the breaker was both beyond his reach on the right side of the airplane and blocked by the right arm of the control column. Other methods of responding to this emergency were available to the pilot; however, due to the jammed trim wheel (there are no emergency procedures that cover this contingency) and a previous experience involving a throttle cable failure, the pilot was convinced he had a flight control failure rather than an autopilot anomaly and did not attempt any alternative actions. Ultimately, the pilot was able to regulate pitch with engine power and landed the airplane gear-up.

Examination of the airframe did not reveal any mechanical failures that would explain why the landing gear did not extend, and following the incident, the landing gear selector switch was found in the down position, and the landing gear circuit breaker was in the pulled (deactivated) position. It is likely that the circuit breaker was inadvertently pulled by the pilot as he tried to disengage the autopilot, and as a result the landing gear did not extend as he had thought. This misdiagnoses further highlights the stress the pilot was experiencing.

No discrepancies were observed in the airplane’s flight control system, and an important service bulletin related to pitch trim runaway had been applied.

Examination of the autopilot system found that the left side rocker of the manual electric trim switch would intermittently fail to return to the neutral position after use. In this state, the trim servo solenoid remained engaged, which locked the trim wheel. However, pulling the pitch trim circuit breaker would have released the solenoid and resolved the anomaly. The damaged rocker switch was therefore likely the reason the pilot was unable to manually adjust the airplane trim during the emergency.

Disassembly of the pitch servo revealed that a bearing in its drive motor had seized and was causing the servo to intermittently stop operating. The design of the servo was such that in the event that it locks, the motor assembly can activate the pitch trim servo to compensate, which could result in a mistrim configuration when the pilot disengages the autopilot. Other possibilities exist that could cause the airplane to be in a mistrim condition with the autopilot enabled, including the pilot manipulating the controls or adjusting the engine speed with the autopilot engaged; however, the pilot stated that he did not do this during the flight.

To prevent deactivation of the autopilot under a mistrim condition, the flight manual specifically calls for pilots to check the command bar on the flight command indicator prior to disengagement. There is no evidence the pilot did this and, as a result, was likely caught off guard by the mistrim condition. Additionally, the pilot did not perform the autopilot pre-flight check prior to flight, which may have alerted him to the anomalies with the trim switch and would have alerted him to another unrelated problem with the pitch trim servo, which was operating slower than required.

Even if the pilot disconnected the autopilot without checking the command bars, the required control forces, while high, would still have been controllable. However, the trim position as found after the incident would have required an extreme application of force (almost 300 lbs) by the pilot at the control wheel to maintain a neutral elevator position, an amount well beyond what the autopilot system could command. Therefore, it is likely that this trim finding was a result of the autotrim system reacting against the pilot’s control input while he attempted to maintain pitch control. It could not be determined why the autotrim system did not completely disengage during this phase of the flight.

The pilot’s previous experience with a throttle failure event likely affected his ability to accurately diagnose the cause and identify an appropriate remedy for the multiple conflicting system cues and failures in a timely manner; his performance was further degraded by the physical workload required to maintain control of the airplane.

Probable cause

A mistrim condition while the autopilot was engaged for reasons that could not be determined based on available evidence, and the pilot’s subsequent failure to confirm the command bar status before disengaging the autopilot. Contributing to the accident were the pilot’s misinterpretation of the event based on a previous unrelated experience, a jammed trim switch, and autopilot disconnect switch which broke off in flight, and the stress induced by the physical exertion required to maintain control of the airplane.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record WPR17IA086
Event ID
20170410X71808
Case number
WPR17IA086
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: investigation status, cause areas. Values present in the bulk record are kept.
  • The date is the local date, which is the same as the UTC date the NTSB stores.
  • API snapshot SHA-256: 9160f2b85cbd328331e4f947f6ff3b39c052c04b036561edb05282e7efc0e15c; retrieved 2026-09-16T05:09:21.733Z.