# NTSB ANC11CA075: Piper PA-32-301, N8152Z, Kodiak, AK, August 12, 2011 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: August 12, 2011, 14:00 local (22:00 UTC) - Place: Kodiak, AK - Coordinates: 57.743057, -152.622772 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=57.7431&lon=-152.6228&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report February 6, 2012 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - Parties: Federal Aviation Administration - Airworthiness - NTSB case key (mKey): 81469 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC11CA075 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/81469/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=81469 - Page: https://openairdocs.org/ntsb/ANC11CA075 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine fuel and control: fuel control/carburetor](https://openairdocs.org/ntsb-findings/01057322): Aircraft › Aircraft power plant · Inadequate inspection (probable cause); cases with it: [Piper PA-32-301, 1 case](https://openairdocs.org/ntsb-findings/01057322/cases.md?model=7103207), [All aircraft, 195 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md) - [Maintenance: repair](https://openairdocs.org/ntsb-findings/02062015): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-32-301, 1 case](https://openairdocs.org/ntsb-findings/02062015/cases.md?model=7103207), [All aircraft, 99 cases](https://openairdocs.org/ntsb-findings/02062015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Piper PA-32-301, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=7103207), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Landing-flare/touchdown: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-32-301, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7103207), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## 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](https://openairdocs.org/deregistered/N8152Z-2011-09-21), registration cancelled 2011-09-21, S/N 32-8006004, built 1980 (OpenAirDocs) - Reported make and model: PIPER PA-32-301 - Registry model: [Piper PA-32-301](https://openairdocs.org/model/piper-pa-32-301) (registry code 7103207) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 32-8006004 - Airframe hours: 14271 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 26; injuries: none; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20110812017859A](https://openairdocs.org/incident/20110812017859A), Aug 12, 2011: Piper PA-32-301, Kodiak, AK, Substantial damage. Pilot departed adq for maintenance check flight of manifold pressure system. On the approach back to adq pilot attemtped to advance the throttles. This is when… ## Other investigations on N8152Z (2) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB ANC05CA102](https://openairdocs.org/ntsb/ANC05CA102), Jul 15, 2005: Piper PA-32-301 (N8152Z), Karluk, AK, substantial damage. Probable cause: A collision with a deer on the runway during the landing roll, which resulted in substantial damage to the tail of the airplane. - [NTSB LAX85LA039](https://openairdocs.org/ntsb/LAX85LA039), Nov 4, 1984: Piper PA-32-301 (N8152Z), Sanger, CA, substantial damage ## Docket (2 files) The files NTSB released with the investigation on December 21, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=81469. 765 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 715 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360307&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Phone Conversation (item 2, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360308&FileExtension=.PDF&FileName=Record%20of%20Phone%20Conversation-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.