CEN13IA270

NTSB incident investigation · Piaggio P180 · Clearwater, FL · April 24, 2013

Incident · No injuriesIncident investigationFinal report
Date
April 24, 2013, 17:20 local (21:20 UTC)
Place
Clearwater, FL
Injuries
6 uninjured
Damage
Minor damage
Phase of flight
Landing
Aircraft
N139SLPiaggio P180
Defining event
Landing-landing roll: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed · report March 24, 2014
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA
FAA report
20130424006479I
Case key
86858

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 failure of the nose landing gear steering manifold during landing, which resulted in an uncommanded and uncontrollable right turn, and the overhaul facility’s improper overhaul of the nose landing gear steering manifold.

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.

Landing gear system: nose/tail landing gearAircraft › Aircraft systems · MalfunctionPiaggio P180: 1 caseAll aircraft: 185 casesProbable cause
MaintenancePersonnel issues › Task performance · Maintenance personnelPiaggio P180: 2 casesAll aircraft: 143 casesProbable cause
Knowledge: knowledge of proceduresPersonnel issues › Experience/knowledge · Maintenance personnelPiaggio P180: 1 caseAll aircraft: 41 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

During landing, the nosewheel touched down, and the pilot heard the tire "squeal" and then felt the airplane gradually veer right. The pilot attempted to correct the turn by applying left rudder, left braking, and left-engine reverse thrust. The airplane came to a stop with the nose pointed more than 90 degrees right of the runway centerline. Examination of the nose landing gear steering manifold revealed that it had recently been overhauled but that the overhaul was not conducted in accordance with the manufacturer's component maintenance manual (CMM); the overhaul facility used unapproved alternative tooling because it did not have the required tooling to conduct the overhaul as specified in the CMM. The nose landing gear steering manifold exhibited internal damage consistent with metal tooling marks that resulted from the use of improper tooling during the overhaul and led to the failure of the nose landing gear steering manifold during landing.

Factual narrative

On April 24, 2013, about 1720 eastern daylight time, a Piaggio P180 airplane, N139SL, received minor damage during a runway excursion at the St. Petersburg-Clearwater International Airport (KPIE), Clearwater, Florida. The air transport pilot and 5 passengers were not injured. The airplane received minor damage to the nose landing gear and wheel. The airplane was registered to Anoil Co. and operated by Avantiar under the provisions of 14 Code of Federal Regulations Part 91 as a business flight. Visual meteorological conditions prevailed for the flight and no flight plan was filed. The local flight originated from KPIE about 1550. During landing, when the nose wheel touched down, the pilot heard the sound of a tire squeal and then felt the airplane gradually veer to the right. The pilot attempted to correct the turn by applying left rudder, left braking, and left engine reverse thrust. The airplane came to a stop with the nose pointed more than 90 degrees to the right of the runway centerline. Only the nose landing gear exited the runway. The operator examined the nose landing gear after the event and performed multiple tests in attempt to determine the cause of the malfunction. When the hydraulics were turned on and the electric steering turned off, the steering actuator actuated the wheels 50 degrees to the right. When the electric steering was turned on, the steering actuator actuated the wheels back to the center position or 0 degrees. The steering manifold, serial number M/DAG74/04; part number 114180003, was removed from the nose landing gear and retained for further examination. The nose landing gear and steering manifold were overhauled by Advantage Aviation Technologies II, LLC (AAT) on March 15, 2013. According to the AAT work order, the steering manifold was overhauled in accordance with Component Maintenance Manual (CMM) 32-50-50, Revision 6. A post incident examination was conducted on the steering manifold. The purpose of this examination was to reveal any mechanical malfunctions or failures of the component. It was also to discover and evaluate the overhaul procedures used by AAT. The testing procedures used by the group were the manufacturer's Component Maintenance Manuals (CMMs) which are the correct manuals to use when overhauling the landing gear and its components. The feedback and control readings were all completed on an analog scale as provided by AAT, not a digital scale as specified in the CMM. The Test Box DRT66770, as specified in the CMM, was not available during testing and was never used by AAT during the overhaul because they do not possess one. A 1985 era Dowty-Rotol Ltd. wiring diagram, 460006820 - sheet 2 of 5, was located at AAT and was used to engineer a replacement test box which was used in all tests performed by AAT and by the group. None of the other required tooling and test boxes, as specified by the CMM, were available at AAT. The steering manifold was first connected to an exemplar Piaggio P180 landinggear. With the system electrically de-energized and hydraulic pressure available the actuator steered left without any commands or inputs. The bias steering check was accomplished and the actuator always actuated to the left. The test was performed twice and the actuator arm moved 6 degrees the first time and about 14 degrees the second time. The tests did not replicate the uncommanded right turn as experienced during the runway excursion. The steering manifold was then connected to a hydraulic test rig and tested per CMM 32-50-50, Revision 8, which was the most current revision at the time of the examination. The group decided that the tests were invalid because ATT did not possess the specified test box. The manifold did not pass any of the other CMM functional tests because the solenoid valve inside the manifold would not close properly. The manifold was then disassembled and examined in order to reveal any anomalies inside the unit that would not allow normal operation. The examination revealed multiple scratches and damage noted to the armature plate and retainer ring. One wave washer and two shims, which measured 0.003 inches in thickness, were located inside the sleeve assembly. The wire connected to the electrical connector was damaged and had a white insulation sleeve placed over it, which ATT had installed during the overhaul. The installation of the insulation sleeve was not a specified procedure in the CMM. A review of the original overhaul paperwork revealed multiple discrepancies. ATT omitted procedures during the overhaul. AAT used alternative tooling which was not approved by the CMM and not referenced in the overhaul paperwork. AAT did not possess any written procedures to which they worked from to validate that the work was completed properly. The manifold was not able to be tested as required in the CMM, as the overhaul facility did not possess the required equipment and tooling and testing equipment.

Aircraft

Registration
N139SL
Reported as
Piaggio P180
Category
Airplane
Serial number
1104
Airframe hours
7,989
Engines
Pratt & Whitney PT6A-66, 850 horsepower, turbo propPratt & Whitney PT6A-66, 850 horsepower, turbo prop
Damage
Minor damage
Flight
Business · Part 91
Operator
Avantair Inc
Registered owner
Anoil Co
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · April 23, 2013 · 2 hours before
Departed
KPIE · Clearwater, FL
Destination
KPIE · Clearwater, FL
Airport
KPIE · St Petersburg-Clearwater Inter, runway 36R, 9,730 × 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
48
Injuries
None
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
January 30, 2013
Seat
Left
Restraint
3-point
Flight hours
6,553 total · 1,115 in this make and model · 9 in the last 90 days · 3 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 61 °F
Altimeter
30.09 inHg
Observed at
KPIE

Docket · 6

The files NTSB released with the investigation on January 31, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 13.5 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.