# NTSB ANC21LA064: Piper PA-14, N4206H, Anchorage, AK, July 23, 2021 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: July 23, 2021, 15:10 local (23:10 UTC) - Place: Anchorage, AK · Discovered at LHD - Coordinates: 61.181371, -149.97211 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=61.1814&lon=-149.9721&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Alaska Regional Office - Parties: FAA - NTSB case key (mKey): 103552 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC21LA064 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103552/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103552 - Page: https://openairdocs.org/ntsb/ANC21LA064 ## Probable cause The fatigue fracture of the American Iron and Steel Institute (AISI) 1025 carbon steel rudder post, which resulted in structural failure of the rudder. Contributing to the fatigue failure was the post’s susceptibility to fatigue cracking under normal service conditions. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Empennage structure: rudder](https://openairdocs.org/ntsb-findings/01035540): Aircraft › Aircraft structures · Failure (probable cause); cases with it: [Piper PA-14, 1 case](https://openairdocs.org/ntsb-findings/01035540/cases.md?model=7101402), [All aircraft, 15 cases](https://openairdocs.org/ntsb-findings/01035540/cases.md) - [Empennage structure: rudder](https://openairdocs.org/ntsb-findings/01035540): Aircraft › Aircraft structures · Fatigue/wear/corrosion (probable cause); cases with it: [Piper PA-14, 1 case](https://openairdocs.org/ntsb-findings/01035540/cases.md?model=7101402), [All aircraft, 15 cases](https://openairdocs.org/ntsb-findings/01035540/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) (defining event); cases with it: [Piper PA-14, 1 case](https://openairdocs.org/ntsb-events/333/sequence.md?model=7101402), [All aircraft, 410 cases](https://openairdocs.org/ntsb-events/333/sequence.md) ## Analysis The pilot reported that while in level cruise flight, frequent left and right rudder inputs were required to keep the inclinometer centered, similar to a light turbulence encounter. The airplane then began to experience a constant yaw, with elevator adjustments required to maintain level flight. He stated that the oscillation then stopped and a “very large right rudder input” was required to maintain the course heading. The pilot was able to maintain control of the airplane and land uneventfully. An initial examination of the rudder revealed that the vertical spar tube separated above the upper hinge point and the top portion of the rudder folded over the horizontal stabilizer tail brace wires. Further examination of the accident airplane’s rudder post found radial features with crack arrest lines, consistent with fatigue from multiple origins at the outer diameter. The piece of post from the upper side of the fracture was further examined using a scanning electron microscope. Multiple fatigue origins were identified on the right side that originated from corrosion pits on the exterior surface. Fatigue fracture features were identified around approximately 1/4 of the circumference on the right side, but the total extent of fatigue cracking could not be determined conclusively due to post-fracture contact damage on the surfaces. Analysis of the rudder post’s material composition found it to be consistent with Piper part number 40622. According to engineering drawings, part number 40622 rudder posts were originally manufactured from American Iron and Steel Institute (AISI) 1025 carbon steel. A Piper engineering change order specified a change to AISI 4130 low-alloy steel that was incorporated into the part number 40622 engineering drawing in June 1974. According to Advisory Circular 23-27, Parts and Materials Substitution for Vintage Aircraft, AISI 4130 low alloy steel generally has more desirable material properties, such as higher tensile ultimate strength, yield strength, and fatigue strength. As part of the NTSB’s investigation of a similar rudder failure on a Piper PA-12, the NTSB performed a rudder loads study that analyzed various structural loads and associated stresses on three other similarly fractured rudders; the posts from these rudders were also found to be consistent with part number 40622 and composed of AISI 1025 carbon steel. The structural load analysis found that, with no scatter factor applied, the bending stress from certification gust and maneuver loads is significantly closer to the endurance limit of AISI 1025 carbon steel than to the endurance limit of AISI 4130 low-alloy steel. In addition, corrosion, scratches, or surface roughness features were observed on each of the rudder posts examined as part of the NTSB’s study, and, as previously stated, examination of the post from this accident identified corrosion pits on the exterior surface. These types of surface anomalies can occur over time during normal operations andcan weaken metal material where they occur. Because AISI 1025 carbon steel has lower overall and fatigue strength than AISI 4130 low-alloy steel, the surface anomalies likely made the affected rudder posts more susceptible to fatigue failure during normal service conditions than they would have been if manufactured with 4130 low-alloy steel. Thus, the rudder failure on the accident airplane was due to the fatigue fracture of the AISI 1025 carbon steel rudder post. Contributing to the fatigue failure was the post’s susceptibility to fatigue cracking under normal service conditions. ## Factual narrative On July 23, 2021, about 1510 Alaska daylight time, a float-equipped Piper PA-14 airplane, N4206H, sustained substantial damage when it’s rudder structurally failed in flight about 15 miles southeast of Anchorage, Alaska. The commercial pilot was uninjured. The airplane was being operated as a Title 14 Code of Federal Regulations Part 91 flight. The pilot reported that while in level cruise flight, frequent left and right rudder inputs were required to keep the inclinometer centered, similar to a light turbulence encounter. The airplane then began to experience a constant yaw, with elevator adjustments required to maintain level flight. He stated that the oscillation then stopped and a “a very large right rudder input” was required to maintain the course heading. The pilot was able to maintain control of the airplane and land uneventfully. Figure - Photo of the damaged rudder. Photo provided by FAA. An initial examination of the rudder revealed that the vertical spar tube separated above the upper hinge point and the top portion of the rudder folded over the horizontal stabilizer tail brace wires. (See figure). When the accident airplane’s rudder was examined, radial features with crack arrest lines were observed, consistent with fatigue from multiple origins at the outer diameter. The piece of post from the upper side of the fracture was further examined using a scanning electron microscope (SEM). Multiple fatigue origins were identified on the right side that originated from corrosion pits on the exterior surface. Fatigue fracture features were identified around approximately ¼ of the circumference on the right side, but the total extent of fatigue cracking could not be determined conclusively due to post-fracture contact damage on the surfaces. The NTSB does not know the exact date of manufacture for this rudder, only the date of manufacture for the airplane. The composition of the rudder post was analyzed using an Olympus Vanta C-Series alloy analyzer. The material associated with the rudder post was identified as carbon steel, consistent with American Iron and Steel Institute (AISI) 1025 carbon steel originally specified for use in the rudder post. According to engineering drawings, the rudder post for Piper part number 40622 was originally manufactured from 0.875-inch diameter, 0.035-inch wall thickness AISI 1025 carbon steel tube. In a Piper engineering change order (ECO) dated June 3, 1974, the specified tube material for the rudder post was changed to normalized AISI 4130 low-alloy steel. The ECO allowed for existing in-process and completed parts to be used to depletion. The material change was incorporated into the part number 40622 engineering drawing in June 1974. The vintage single-engine Piper airplane model types from which these rudders were obtained were designed for static load conditions as required by the regulations in place at the time they were certified. However, in service, the loading conditions on many parts of theseairplanes’ structures, including the rudders, are not static and contain dynamic alternating or repeated (fatigue) loads. It is well documented that fatigue failures in metal occur at stress levels well below the static strength stress levels. Aircraft designed in accordance with modern regulations are required to account for fatigue loads. To assess the implications of this, the NTSB conducted a structural load analysis for three of the rudders with no scatter factor applied and found that the bending stresses on the rudder posts from certification gust and maneuver loads are significantly closer to the endurance limit for posts made of AISI 1025 carbon steel than they are for those made of AISI 4130 low-alloy steel. FAA Advisory Circular 23-27, “Parts and Materials Substitution for Vintage Aircraft,” published in 2009, specifically advises that AISI 4130 low-alloy steel may be substituted for AISI 1020 or AISI 1025 carbon steel, including for structural posts on applicable aircraft. The advisory circular clarifies that this is because AISI 4130 low alloy steel is more widely available and generally has more desirable material properties, such as higher tensile ultimate strength, yield strength, and fatigue strength. ## Aircraft - Registration: [N4206H](https://openairdocs.org/aircraft/N4206H), registered now, S/N 14-9, built 1948 (OpenAirDocs) - Reported make and model: PIPER PA-14 - Registry model: [Piper PA-14](https://openairdocs.org/model/piper-pa-14) (registry code 7101402) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 14-9 - Year built: 1948 - Airframe hours: 2691.1 - Engines: LYCOMING O-320 SERIES 160 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 4, 2021, 29.3 hours before - Destination: Same as departure - Airport: LHD, Lake Hood, runway N/S, 1,930 × 200 ft, water - Equipment: Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; injuries: none; commercial; airplane ratings: multi-engine land, single-engine sea, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review May 27, 2021; seat: left; restraint: 4-point; flight hours: 1,900 total, 304.1 in this make and model, 1,826.2 as pilot in command, 92 in the last 90 days, 24.9 in the last 30 days, 7.1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: 6,000 ft overcast - Temperature: 63 °F, dew point 52 °F - Altimeter: 29.90 inHg - Observed at: PALH - METAR: PALH 240153Z 18004KT 10SM OVC060 17/11 A2990 RMK AO2 SLP127 T01720111 ## 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 20210723011379A](https://openairdocs.org/incident/20210723011379A), Jul 23, 2021: Piper PA-14, Anchorage, AK, Substantial damage. In cruise flight and without warning, the rudder post broke just above the top hinge. The upper part of the rudder folded over to a point just above the tail… ## Docket (7 files) The files NTSB released with the investigation on January 21, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103552. 36.4 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 31.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12872807&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Materials laboratory factual report 21-068 (item 2, PDF, 8 pages, 9 photos, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12799624&FileExtension=pdf&FileName=21-068-Rel.pdf - NTSB rudder study (item 3, PDF, 16 pages, 853 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13127512&FileExtension=pdf&FileName=ANC20LA059%20Structures%20Rudder%20Study-Rel.pdf - NTSB rudder study appendix a - rudder drawings (item 4, PDF, 4 pages, 199 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13127522&FileExtension=pdf&FileName=ANC20LA059%20Structures%20Appendix%20A%20-%20Rudder%20Drawing-Rel.pdf - NTSB rudder study appendix b - rudder loads (item 5, PDF, 3 pages, 214 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13127204&FileExtension=pdf&FileName=ANC20LA059%20Structures%20Appendix%20B%20-%20Rudder%20Loads-Rel.pdf - NTSB rudder study appendix c - USAF rudder kt study (item 6, PDF, 18 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13126995&FileExtension=pdf&FileName=ANC20LA059%20Structures%20Appendix%20C%20-%20Rudder%20Tube%20Kt%20Study-Rel.pdf - Photo (item 7, PDF, 1 page, 216 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12872704&FileExtension=pdf&FileName=Docket%20Photo-Rel.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.