ANC11CA075

NTSB accident investigation · Piper PA-32-301 · Kodiak, AK · August 12, 2011

Accident · No injuriesData collectionFinal report
Date
August 12, 2011, 14:00 local (22:00 UTC)
Place
Kodiak, AK
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N8152ZPiper PA-32-301
Defining event
Approach-VFR pattern final: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report February 6, 2012
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
Federal Aviation Administration - Airworthiness
FAA report
20110812017859A
Case key
81469

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

A partial loss of engine power while on approach to land due to a disconnected throttle control linkage, and the maintenance director's inadequate inspection of the throttle linkage during maintenance.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Engine fuel and control: fuel control/carburetorAircraft › Aircraft power plant · Inadequate inspectionPiper PA-32-301: 1 caseAll aircraft: 195 casesProbable cause
Maintenance: repairPersonnel issues › Task performance · Maintenance personnelPiper PA-32-301: 1 caseAll aircraft: 99 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot and the operator's director of maintenance (DOM) were on a postmaintenance check flight. According to the pilot, while approaching to land, the throttle control became inoperative, resulting in a partial loss of engine power. The pilot selected a tidal beach as a forced landing site but was unable to reach it and landed in shallow water short of the site. The airplane sustained substantial damage to the wings and fuselage. The DOM reported that, while troubleshooting a recurring complaint of low engine manifold pressure, he noticed that the castellated nut, which connects the throttle linkage to the fuel control servo, was loose. He said that he removed the cotter pin, tightened the nut, and reinstalled the cotter pin. A postaccident engine examination revealed that a self-locking nut was missing from the throttle linkage arm, resulting in the disconnection of the throttle cable. The DOM said that the missing locknut was not the same one that he tightened but was a nut on the other end of the throttle linkage arm, about 2 inches from the castellated nut that he tightened. The DOM noted that he should have checked the security of the self-locking nut, but he did not. The self-locking nut was not recovered.

Factual narrative

The pilot and the operator's director of maintenance (DOM), were on a postmaintenance check flight. According to the pilot's written statement, while approaching to land, the throttle control became inoperative, resulting in a partial loss of engine power. The pilot selected a tidal beach as a forced landing site, but was unable to reach it, and landed in shallow water short of the site. The airplane sustained substantial damage to the wings and fuselage. In a written statement to the NTSB, the DOM reported that while troubleshooting a recurring complaint of low engine manifold pressure, he noticed that the castellated nut, which connects the throttle linkage to the fuel control servo, was loose. He said he removed the cotter pin, tightened the nut, and reinstalled the cotter pin. A postaccident engine examination revealed that a self-locking nut was missing from the throttle linkage arm, resulting in the disconnection of the throttle cable. The DOM said that the missing locknut was not the same one that he removed, tightened and reinstalled, but was a nut on the other end of the throttle linkage arm, about 2 inches from the castellated nut that he tightened. The DOM noted that he should have checked the security of the hexagon self-locking nut, but he did not. The hexagon self-locking nut was not recovered.

Aircraft

Registration
N8152Z
Reported as
Piper PA-32-301
Category
Airplane
Serial number
32-8006004
Airframe hours
14,271
Engine
Lycoming IO-540 SER, 260 horsepower, reciprocating
Damage
Substantial damage
Flight
Flight test · Part 91
Operator
Redemption, Inc., doing business as Island Air
Registered owner
Cdc Corp
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 13, 2011 · 86 hours before
Departed
PADQ · Kodiak, AK
Destination
PADQ · Kodiak, AK
Flight plan
Company VFR
Airport
PADQ · Kodiak, runway 29, 5,399 × 150 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
26
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
January 31, 2011
Seat
Left
Flight hours
2,575 total · 509 in this make and model · 244 in the last 90 days · 80 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 11 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
64 °F, dew point 48 °F
Altimeter
30.09 inHg
Observed at
PADQ

Docket · 2

The files NTSB released with the investigation on December 21, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 765 KB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N8152Z · 2

Matched to the same aircraft by N-number and date.