CEN13LA208

NTSB accident investigation · Cessna 421C · Amarillo, TX · March 27, 2013

Accident · No injuriesLimited investigationFinal report
Date
March 27, 2013, 10:45 local (15:45 UTC)
Place
Amarillo, TX
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N805DCCessna 421C
Defining event
Landing-landing roll: Landing gear collapse
Weather
Visual (VMC) · Day
Status
Completed · report November 3, 2014
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA- Lubbock, TX FSDO
FAA report
20130327003749A
Case key
86528

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

Maintenance personnel's failure to detect the misadjustment of the left landing gear actuator's switch after recent maintenance, which prevented the landing gear from locking in the extended position and resulted in the landing gear collapsing during landing.

Findings · 2

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: landing gear actuatorAircraft › Aircraft systems · Incorrect service/maintenanceCessna 421C: 1 caseAll aircraft: 54 casesProbable cause
Inspection: post maintenance inspectionPersonnel issues › Task performance · Maintenance personnelCessna 421C: 1 caseAll aircraft: 57 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

The airplane's left landing gear collapsed during landing. Postaccident examination of the landing gear system revealed that the down-lock indicator switch on the left landing gear actuator had been turned about 1/2 turn farther inward than specified in the actuator manufacturer's assembly instructions. This incorrect adjustment of the left landing gear indicator switch resulted in the switch's plunger interfering with the actuator's internal locking mechanism, which prevented the actuator from locking in the down position. It also resulted in the left landing gear position indicator showing a down-and-locked position regardless of the gear's actual position. Maintenance records indicated that both main landing gear actuators were resealed at the annual inspection about 1 month before the accident. The maintenance manual included procedures for electrically testing the landing gear actuator switch for proper indication of the unlocked and locked conditions. If maintenance personnel had conducted the testing during the recent maintenance, the misadjusted switch likely would have been discovered.

Factual narrative

On March 27, 2013, about 1045 central daylight time, a Cessna 421C, N805DC, sustained substantial damage when its left main landing gear collapsed during landing at the River Falls Airport, Amarillo, Texas. The airplane subsequently exited the left side of the runway where the right main landing gear and the nose landing gear separated from the airplane. The pilot was not injured. The airplane sustained substantial damage to its wings and fuselage. The airplane was registered to and operated by PMT Flyers LLC under the provisions of 14 Code of Federal Regulations Part 91 as a maintenance positioning flight. Visual meteorological conditions prevailed for the flight, which operated on a visual flight rules flight plan. The flight originated from Amarillo International Airport, Amarillo, Texas, about 1040. The pilot reported that while in the traffic pattern he extended the gear and noted that the three green landing gear lights illuminated indicating that the gear was down and locked. He stated that upon landing he touched down initially on the right wheel due to the crosswind correction and when the airplane settled on the left gear it continued until the left wing tip struck the ground. Examination of the airplane after the accident revealed that all three gear down indicator lights were illuminated despite the left gear being collapsed into the wheel well. After raising the airplane the landing gear was extended and it was found that inward pressure on the left main landing gear would cause the actuator to unlock allowing the gear to fold inward. Further examination and testing revealed that the down lock microswitch on the actuator remained in an electrically closed position regardless of the position of the landing gear. As the switch was being removed from the actuator, the switch contacts opened after the switch housing was rotated about 1/8 of a turn. The assembly instructions from the actuator manufacturer's overhaul manual stated: "Hydraulically or manually extend and lock actuator. Lightly coat plunger of switch (3) and plunger (4) with silicone fluid (see note above) and install into gland (16). Install switch (3) with nut and washer saved from disassembly, into gland. Adjust switch so that the electrical signal comes on (continuity between leads (1 & 3) and (4 & 6) see figure 601) then turn another 90° ± 10°." Disassembly of the actuator revealed that the switch plunger interfered with the internal locking mechanism of the actuator preventing it from properly locking in the extended position. The as found position of the switch was approximately 1/2 turn farther inward than specified in the assembly instructions. Once the down lock microswitch was adjusted according to the manufacturer's instructions the actuator and switch functioned normally and the actuator would lock in the extended position. Maintenance records showed that both main landing gear actuators had been resealed at the last annual inspection on February 19, 2013. Themechanic that performed the maintenance reported that the maintenance was performed using guidance from the manufacturer's maintenance manual. He stated that that the actuator was only disassembled to a point that allowed replacing the seals in the end cap assembly that the piston rod passes through and that no adjustment of the gear indicator switch was performed. The maintenance manual had procedures for operational testing after maintenance was performed. The procedures included electrically testing the switch for proper indication of unlocked and locked conditions.

Aircraft

Registration
N805DC
Reported as
Cessna 421C
Category
Airplane
Serial number
421C0065
Airframe hours
7,000
Engines
Cont Motor TSIO-520 SER, 300 horsepower, reciprocatingCont Motor TSIO-520 SER, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 19, 2013
Departed
AMA · Amarillo, TX
Destination
81XA · Amarillo, TX
Airport
81XA · River Falls Airport, runway 17, 4,500 × 60 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
37
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Left

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 11 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
59 °F, dew point 19 °F
Altimeter
30.04 inHg
Observed at
AMA, 9 nm away

Docket · 11

The files NTSB released with the investigation on September 26, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 22.4 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.