ANC21LA022

NTSB accident investigation · Cessna A185F · Skwentna, AK · March 5, 2021

Accident · No injuriesClass 3 · LimitedFinal report
Date
March 4, 2021, 15:00 local (Mar 5, 2021, 00:00 UTC)
Place
Skwentna, AK · Trinity Lake
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N1848RCessna A185F
Defining event
Initial climb: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Alaska Regional Office
Parties
FAA, Airglas, Inc.
FAA report
20210304001109A
Case key
102736

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

On this page

Probable cause

Installation of improper hardware on the ski check cable. Contributing to the accident was the inadequate inspection of the ski yokes, which resulted in the subsequent failure of the right main landing gear ski yoke and collapse of the right main landing gear during the precautionary landing.

Findings · 5

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.

Misc hardware: fastenersAircraft › Fluids/misc hardware · Incorrect use/operationCessna A185F: 1 caseAll aircraft: 58 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelCessna A185F: 1 caseAll aircraft: 167 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · PilotCessna A185F: 1 caseAll aircraft: 167 casesProbable cause
Landing gear system: wheel/ski/floatAircraft › Aircraft systems · Not inspectedCessna A185F: 6 casesAll aircraft: 48 casesProbable cause
Landing gear system: wheel/ski/floatAircraft › Aircraft systems · FailureCessna A185F: 6 casesAll aircraft: 48 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

After takeoff from the remote frozen snow-covered lake, with the hydraulic-wheel-ski-equipped airplane, the unapproved retainer clip that the pilot had installed holding the right rear ski check cable disconnected for undetermined reasons. Subsequently, the right rear check cable “came loose” from the fuselage attach fitting and the right ski rotated to a nose-high position. The pilot was able to maintain control of the airplane; however, a “very serious” vibration was noted in the right horizontal stabilizer, and he chose to return to the departure lake to make a precautionary landing. The pilot landed on untracked snow and as the ski was coming down “into its normal landing position,” the airplane veered hard to the right. The right main landing gear separated from the fuselage and the right wing impacted the snow. The fuselage sustained substantial damage. There was a service bulletin (SB) published for the inspection and replacement of the ski yoke. The pilot reported that both he and his mechanic were unaware of the SB and that it had not been complied with. Compliance with information in the SB was not mandated by the Federal Aviation Administration. The weld applied to the yoke joints failed due to lack of penetration of the weld metal into the base metal of the joints. The failure was a known issue and thus the accident could have been prevented by either continuous inspections of the welds, installation of the finger strap repair, or replacement of the yoke.

Factual narrative

On March 4, 2021, about 1500 Alaska standard time, a Cessna A185F, N1848R, was substantially damaged when it was involved in an accident near Skwentna, Alaska. The pilot and three passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, after takeoff from the remote frozen snow-covered lake, with the hydraulic-wheel-ski-equipped airplane, the right rear check cable “came loose” from the fuselage attach fitting. The right ski then rotated to a nose high position as he maintained control of the airplane. His initial decision was to fly to the Lake Hood Airport (LHD), Anchorage, Alaska; however, a “very serious” vibration was noted in the right horizontal stabilizer, and he decided to return to the departure lake to make a precautionary landing. While landing on loose, untracked snow, as the heel of the right ski touched the snow, the tip of the ski lowered, and the ski pivoted “into its normal landing position.” The airplane veered hard to the right, the right main landing gear separated from the fuselage, and the right wing impacted the snow. The fuselage sustained substantial damage. A post-accident examination of the right wheel-ski assembly revealed that the retainer clip that secured the aft check cable to the fuselage fitting became detached and was missing. The pilot had installed the retainer clip which was not approved by the ski manufacturer. Additionally, the pilot reported that the ski yoke had fractured at a weld site. The airplane was equipped with Airglas LH4000 hydraulic wheel-skis. The pilot reported that the skis equipped on the airplane were manufactured in either 2010 or 2011. The manufacturer issued a service bulletin (SB) on the skis in March 2018. The SB states in part: Airglas has received 4 reports of the LH4000 yoke (PN LH3600-5) of the welds shearing off the outboard arm of the yoke. The common thread between all occurrences is a heavy side load is applied to the skis. This sideways load appears to happen in a turn. In three cases, pilot reported to Airglas that they hit an obstruction in a turn. The yokes Airglas manufactured up until 2014 were manufactured differently than current yoke. The older yokes were welded and then post heat-treated, followed by a mag-particle inspection. We have also seen some evidence that yokes may have been partially cracked, prior to final heavy side load occurrence. The yokes are powder coated, and this may be masking partial cracks. Compliance: Mandatory: This service document must be accomplished at the next 50-hours. Note: After the initial inspections, this service letter inspection must be completed every 50 hours. The pilot stated that he and his mechanic were unaware of the SB. Compliance with the information in the SB was also not mandated by the Federal Aviation Administration. Examination The pilot reported that he had just replaced the ski check cables several months prior to the accident,due to aging wear. He added that he had the mechanic then sign the installation off. The retainer clip used to secure the right rear check cable hardware was not recovered. Examination of the components indicated that the rear check cables on the skis were attached with unapproved hardware. The cables are supposed to be attached with a cotter key and instead were secured using a retainer clip. A National Transportation Safety Board Materials Engineer examined the damaged ski components and noted that the outboard arm separated from the yoke through the weld metal at the attaching joints. The separations were only through the weld filler metal – the outboard arm members and the main yoke body were undamaged. Examination of the joints revealed thin weld metal deposits that did not penetrate the base metal of the parts and appeared to bond only to the tube surface. The ends of the outboard members were smooth and consistent with machined metal, and there were wear patterns consistent with contact marks from the mating outboard arm members on the surface of the main yoke body at the joints.

Aircraft

Registration
N1848R
Reported as
Cessna A185F
Category
Airplane
Serial number
18502563
Built
1974
Airframe hours
3,375
Engine
Cont Motor IO 520 D, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 18, 2021
Destination
4AK6 · Wasilla, AK
Airport
Trinity Lake
Equipment
ADS-B, Stall warning system

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
70
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Helicopter
Medical
Class 2, With waivers/limitations
Last flight review
June 14, 2019
Seat
Left
Restraint
3-point
Flight hours
20,000 total · 1,900 in this make and model · 15,000 as pilot in command · 15 in the last 90 days · 5 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 3 knots
Visibility
10 statute miles
Temperature
28 °F, dew point 12 °F
Altimeter
29.74 inHg
Observed at
PAWS, 55 nm away
METAR
PAWS 042356Z AUTO 29003KT 10SM CLR M02/M11 A2974 RMK AO2 SLP081 T10171111 10000 21183 56012 FZRANO

Docket · 11

The files NTSB released with the investigation on November 4, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.9 MB 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.