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Atlas / NTSB / CEN23LA363

NTSB CAROL · Event

Event CEN23LA363

2023-08-15 Lansing, Michigan, United States Airport · LAN Minor 1 aircraft Status: Completed

Aircraft involved

Probable cause & findings

The pilot’s failure to properly set the rudder trim position which resulted in a loss of directional control during takeoff. Contributing was the pilot’s inadequate checklist procedures prior to takeoff.

Factual narrative

The pilot reported that after a normal start and taxi, the airplane was cleared for takeoff. During the takeoff roll, the airplane drifted right and the pilot corrected with the left rudder. When the airplane reached 100 knots, he rotated the airplane, and about 30 feet in altitude, the airplane experienced a roll to the right. The pilot tried to correct the roll with left rudder but was unable to provide sufficient left rudder. At this point, the airplane had drifted to the right of the runway and over the adjacent parallel taxiway. He was able to regain partial control by reducing engine power and banking the airplane to the left. The pilot attempted to land on the taxiway but was unable to judge his height above ground due to the low visibility, and subsequently impacted terrain to the right of the taxiway. Both wings and the fuselage sustained substantial damage. Prior to exiting the airplane, the pilot noted that the rudder trim was set to the full nose-right position. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. Prior to the accident, maintenance was completed that consisted of an “Event II & Routine” inspection. The inspection procedure required the rudder trim system to be lubricated, a trim tab free play inspection, and an operational check prior to returning the airplane to service. Review of the maintenance procedures revealed there was no guidance on returning the rudder trim control system back to a neutral position at completion of the inspection. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12

NTSB Findings

Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).

  • Aircraft-Aircraft systems-Flight control system-Rudder tab control system-Incorrect use/operation
  • Personnel issues-Task performance-Inspection-Preflight inspection-Pilot
  • Personnel issues-Task performance-Use of equip/info-Use of checklist-Pilot
  • Organizational issues-Management-Policy/procedure-Adequacy of policy/proc-Operator
  • Aircraft-Aircraft handling/service-Maintenance/inspections-Return to service-Related maintenance info
  • Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot

Verbatim from NTSB's published report. Source file NTSB_2023_CEN23LA363.txt. Findings + structured fields enriched from FAA avall.mdb. Full investigation docket on data.ntsb.gov ↗.

Related research

What the literature says.

Academic papers and agency reports matching this event's aircraft type or causal vocabulary (maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.

Browse the full corpus — academia portal ↗