CEN10IA554

NTSB incident investigation · Diamond Aircraft Ind DA 20-C1 · Bloomington, IL · August 26, 2010

Incident · No injuriesIncident investigationFinal report
Date
August 26, 2010
Place
Bloomington, IL
Injuries
1 uninjured
Damage
Minor damage
Phase of flight
Prior to flight
Aircraft
N409AMDiamond Aircraft Ind DA 20-C1
Defining event
Prior to flight: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Not reported
Status
Completed · report May 16, 2011
Report
Approved by Office Director
NTSB office
Central Region
Parties
Transportation Safety Board of Canada, Diamond Aircraft Industries Inc., Federal Aviation Administration
Case key
77382

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

On this page

Probable cause

The cracked nose landing gear fork assembly found during the preflight inspection.

Findings · 3

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.

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

A student pilot found a cracked nose landing gear (NLG) fork, which was the third cracked fork the operator reported in the previous 17 months. A Federal Aviation Administration (FAA) Service Difficulty Report (SDR) query revealed there were 12 SDR reports on the NLG forks, which included the three from the incident operator. Another operator had a fleet of 44 airplanes. This fleet’s airplanes accumulated 13 cracked NLG forks in 17 months. According to a fleet representative, their normal procedure for reporting failed parts was to submit the information directly to the manufacturer, instead of submitting a SDR. The airplane’s manufacturer recommended the installation of screws in the bolt holes used to secure the fairing to the NLG fork, which reportedly reduced a stress concentration point. The airplane manufacturer published a Service Information Letter (SIL), which depicted a replacement NLG fork assembly, and described the installation process. The SIL also referred owners to the maintenance manual for new inspection requirements that require the NLG to be inspected every 100 hours as opposed to the previous 6,000-hour inspection cycle. The National Transportation Safety Board issued recommendations to the FAA to encourage "all persons or organizations that operate under 14 CFR Parts 43 and 91 to submit Malfunction or Defect Reports ... and to ... encourage foreign regulatory agencies to provide service difficulty data from resident operators and manufacturers to the FAA for incorporation into the FAA service difficulty data base."

Factual narrative

On August 26, 2010, at time unknown, a Diamond Aircraft Industries Inc. DA 20-C1 airplane, N409AM, exhibited minor damage when a student pilot found a crack on its nose landing gear (NLG) fork during a preflight inspection at the Central Illinois Regional Airport at Bloomington-Normal, near Bloomington, Illinois. Visual meteorological conditions prevailed all day in the area. The operator reported no injuries. The instructional flight was to be operated under 14 Code of Federal Regulations Part 91. This cracked NLG fork, found by the student pilot during the preflight of the incident airplane, was the third cracked fork that the operator reported since March 30, 2009. The two previous cracked NLG fork occurrences were reported on April 7, 2009 and on March 30, 2009. This recent NLG fork accumulated 573.6 hours of total time before the crack was observed and the two previous forks accumulated 1,306.0 hours and 1,926.7 hours respectively. The incident airplane’s last inspection was a 100-hour inspection and it was completed on July 23, 2010. The cracks were in similar locations for all three occurrences. The NLG forks’ arms exhibited cracking near the bolt hole that is used to secure the fairing to the NLG fork. The NLG forks' part number (p/n) were: 20-3220-08-00. The Federal Aviation Administration Service Difficulty Report (SDR) query page was queried to determine how many Diamond Aircraft Industries Inc. cracked NLG forks were reported. There were 12 SDR reports on the NLG forks, which included the three from the incident operator. Another operator of DA 20-C1 airplanes was contacted in reference to NLG fork cracking. This operator had a fleet of 44 DA 20-C1 airplanes which were also used for flight instruction. A representative for this operator reported that his fleet’s airplanes averaged about 60 hours of flight time per month and that the fleet accumulated 13 cracked NLG forks between February 24, 2009 and July 14, 2010. He said that the NLG forks are replaced and a condition report is submitted directly to the manufacturer, which is their normal procedure for failed parts. Their total time on the forks before the cracks were observed ranged from 595.9 hours to 2,253.9 hours with an average of 1,371.09 hours. The representative further stated that the airplane’s manufacturer recommended the installation of screws in the bolt holes that are used to secure the fairing to the NLG fork. The installation was indicated to reduce a stress concentration point. Diamond Aircraft Industries Inc. had been working on a design change at the time of the incident with N409AM and subsequently published a Service Information Letter (SIL) 20C1-005. The SIL advised owners, worldwide, that the old NLG fork assembly P/N 20-3220-08-00 had been replaced with the new fork assembly, P/N 20-3220-08-00_1. The SIL further advised customers to install machine screws, pan head, P/N MS35207-282, with Loctite 242 when the wheel fairings are not used to avoid any potentialcracking that also may occur at that location. Lastly, the SIL refers owners to the Aircraft Maintenance Manual (AMM), Revision 17, dated November 1, 2010, for new inspection requirements for the NLG. The airplane inspection schedule in the AMM indicated that the NLG is now to be inspected every 100 hours as opposed to the previous revision’s 6,000-hour inspection cycle. The National Transportation Safety Board, in a letter dated June 3, 1993, to the FAA Administrator, issued recommendations in reference to SDRs. The letter, in part, stated: The Federal Aviation Administration's Service Difficulty Reporting (SDR) program is often used during aviation accident/incident investigations to research the history of aircraft failures, malfunctions, and defects. However, attempts to effectively use the SDR data base in recent Safety Board investigations have revealed that the current program is incomplete and of limited value in identifying accurate service defect histories because many reportable service difficulties are not reported to the FAA. ... The Safety Board is also concerned that the current efforts to improve the SDR system do not address the problems with general aviation Malfunction or Defect (M or D) Reports. Current Federal Aviation Regulations (FARs) require that holders of certificates under 14 Code of Federal Regulations (CFR) Parts 21, 121, 125, 127, 135, and 145 submit reports of service difficulties to the FAA for entry into the SDR system. Service difficulty reporting is currently not required under Parts 43 and 91. This factor may be contributing to low reporting, which significantly reduces the value and effectiveness of the program. Encouraging those who operate under the provisions of 14 CFR Parts 43 and 91 to submit M or D Reports, and providing appropriate guidance to them, would improve the quality and content of the general aviation SDR data base. The letter included the following recommendations to the FAA: Review the reporting items and establish standardized reporting formats for Malfunction or Defect Reports and Service Difficulty Reports that include the capability for electronic submission. Encourage all operations under 14 CFR Parts 21, 43, 91, 121, 125, 127, 135, and 145 to use electronic reporting methods for submission of service difficulty information. (Class II, Priority Action) (A-93-61) Encourage all persons or organizations that operate under 14 CFR Parts 43 and 91 to submit Malfunction or Defect Reports and provide appropriate guidance to improve the quality and content of the general aviation service difficulty data base. (Class II, Priority Action) (A-93-62) Ensure that prompt analysis of service difficulty reports and dissemination of alerting information is being accomplished in accordance with Federal Aviation Administration policies and procedures. (Class II, Priority Action) (A-93-63) Encourage foreign regulatory agencies to provide service difficulty data from resident operators and manufacturers tothe Federal Aviation Administration (FAA) for incorporation into the FAA service difficulty data base. (Class II, Priority Action) (A-93-64) The status of these recommendations, at the time of publishing of this incident report, are closed-unacceptable action for A-93-61 and closed-acceptable action for A-93-62, A-93-63, and A-93-64.

Aircraft

Registration
N409AM
Reported as
Diamond Aircraft Ind DA 20-C1
Category
Airplane
Serial number
C0343
Airframe hours
1,801
Engine
Cont Motor IO-240-B, 125 horsepower, reciprocating
Damage
Minor damage
Flight
Instructional · Part 91
Operator
Image Air Of Southwest Florida Lc
Registered owner
Image Air Of Southwest Florida Lc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 23, 2010
Departed
BMI · Bloomington, IL
Destination
BMI · Bloomington, IL
Flight plan
Unknown
Airport
BMI · Central Illinois Regional

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
Injuries
None
Certificate
Student
Medical
Class 3, Unknown

Weather

Conditions
Visual (VMC) · Not reported
Visibility
10 statute miles
Observed at
BMI

Docket · 5

The files NTSB released with the investigation on January 10, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.6 MB in all.