CEN13LA524

NTSB accident investigation · Stemme S10-VT · Mackinaw City, MI · August 31, 2013

Accident · Serious injuriesLimited investigationFinal report
Date
August 30, 2013, 20:15 local (Aug 31, 2013, 01:15 UTC)
Place
Mackinaw City, MI
Injuries
1 serious, 1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N389BDStemme S10-VT
Defining event
Approach-VFR pattern final: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Dusk
Status
Completed · report September 24, 2014
Report
Approved by Office Director
NTSB office
Central Region
FAA report
20130830017809A
Case key
87970

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

The mechanic’s failure to inspect the tightness of the bolts that connected the flexible disk to the driveshaft, which resulted in the failure of these components.

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.

AircraftAircraft › Aircraft propeller/rotor · FailureStemme S10-VT: 1 caseAll aircraft: 11 casesProbable cause
AircraftAircraft › Aircraft propeller/rotor · Incorrect service/maintenanceStemme S10-VT: 1 caseAll aircraft: 11 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelStemme S10-VT: 1 caseAll aircraft: 320 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 pilot reported that the motor-glider was on a long, straight-in visual approach to land when he heard a very loud "bang" in the front of the motor-glider followed by a severe vibration. The pilot shut down the engine and made a forced landing to a field. A postaccident examination of the aircraft revealed that the flexible disk on the front of the driveshaft had disconnected. Only one of the three bolts that connected the disk to the driveshaft remained partially installed. No evidence of Loctite or torque paint was found on the bolt. The bolt's threads were rusted, and the bolt's head was digging into the gearbox housing. The second bolt was sheared off, and the third bolt was missing. A review of maintenance records revealed that the motor-glider's most recent annual inspection was completed about 1 month before the accident. According to the manufacturer's maintenance manual, a mechanic was required to check the tightness of the bolt connections of the flexible disk on the front side of the drive shaft. It is likely that the mechanic improperly inspected the bolts that connected the flexible joint to the front side of the driveshaft during the last annual inspection, which resulted in the ultimate failure of these components. The maintenance records also revealed that, during the last annual inspection, Federal Aviation Administration Airworthiness Directive (AD) 2006-19-08, which required inspection for deformations and cracks in the exhaust pipes and the replacement of any damaged exhaust pipes found, had not been properly complied with when a weld repair was made to the No. 1 exhaust pipe. The mechanic's failure to not properly comply with the AD and the operator's failure to ensure that the AD was complied with were not causal to the accident; however, because the AD was not complied with, the motor-glider was not considered airworthy.

Factual narrative

On August 30, 2013, about 2015 eastern daylight time, N389BD, a Stemme GMBH S10-VT motor-glider, sustained substantial damage during a forced landing near Mackinaw City, Michigan. The private pilot/owner sustained serious injuries and the passenger was not injured. Visual meteorological conditions prevailed for the personal flight conducted under 14 Code of Federal Regulations Part 91. No flight plan was filed for the cross-country flight that originated from the Waukegan Regional Airport (UGN), Chicago/Waukegan, Illinois, about 1530, and destined for Mackinaw County Airport (83D), St. Ignace, Michigan.The pilot stated that he was on a long, straight in visual approach to land at an altitude about 2,000 feet, when he heard a very loud "bang" in the front of the motor-glider. The bang was followed by a severe vibration. The pilot reduced power, which dampened the vibrations; however, he was unable to maintain altitude. The pilot shut down the engine and made a forced landing to a field. Just prior to landing, the motor-glider struck two dead trees and landed inverted, resulting in substantial damage to the airframe and wings. An inspector with the Federal Aviation Administration (FAA) performed a postaccident examination of the motor-glider. The inspector stated that the propeller housing, gearbox, forward bulkhead and instrument panel were all pushed aft several inches from impact forces. Both propeller blades were in the stowed position, but the upper left propeller housing mount was bent and the propeller could not be manually rotated. One blade had free folding movement throughout its range with spring tension to return it to the stowed position. The second blade was binding throughout its folding motion and had little to no spring tension. The inspector said enough "usable fuel" was observed in the right fuel tank but the left wing fuel tank was breached and no fuel was observed. The fuel selector valve was in its normally open position. The inspector was unable to gain access to the driveshaft, which ran underneath the cockpit between the propeller and the engine. The airplane was moved to a repair facility in California that specializes in Stemme motor-gliders for further examination. The examination revealed that the flexible disk (cardanic joint) on the front side of the driveshaft had disconnected. The disk and driveshaft are secured together by three bolts. One of the bolts was partially installed and there was no evidence of Loctite 243 or torque paint. The threads of the bolt were rusted and the head of the bolt was digging into the gearbox housing. The second bolt was sheared off and the third bolt was missing. An FAA inspector who examined the flexible disk (cardanic joint) and driveshaft after it had been removed from the motor-glider said the bolts that secured the flexible disk to the front of the driveshaft appeared to have fallen out and no Loctite 243 was present to indicate the bolts had been properly installed. Themotor-glider was manufactured in 2001. A review of the maintenance logbooks revealed that the last annual inspection was completed on July 26, 2013, at an aircraft total time of 322.7 hours. According to the Stemme S10-VT maintenance manual, the flexible disc (cardanic joint) was to be inspected at each annual inspection. The maintenance manual stated, "Check condition (cracks and embrittlement of rubber) and tight screw connections of cardanic rubber disc joint on freewheel clutch and on forward drive shaft. To inspect rubber discs for cracks and embrittlement, apply a torsional load on the discs and observe rubber surface." It was also noted that during the last annual inspection that FAA Airworthiness Directive (AD) 2006-19-08, which required a mandatory inspection for deformations and cracks in the exhaust pipes, had not been properly complied with when a weld repair was made to the No.1 exhaust pipe. The AD specifically stated, "If any damage (deformation, cracks, and/or flattening) is found in the inspection...replace the damaged exhaust pipe." According to Federal Aviation Regulations (FAR) Part 39, ADs are legally enforceable rules that apply to the following products: aircraft, engines, propellers, and appliances. They specify required inspections, conditions and limitations, and any actions to resolve an unsafe condition. Anyone who operates a product that does not meet the requirements of an applicable airworthiness directive is in violation of this section. If a certified aircraft has outstanding airworthiness directives that have not been complied with, the aircraft is not considered airworthy. Additionally, a review of the maintenance logbooks identified several other maintenance items that were not complied with as per the Stemme S10-VT maintenance manual. In 2010, the propeller was not properly balanced and it had exceeded the required 5 year overhaul inspection.

Aircraft

Registration
N389BD
Reported as
Stemme S10-VT
Category
Glider
Serial number
11-066
Built
2001
Airframe hours
600
Engine
reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
512 Horses Inc
Registered owner
512 Horses Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 20, 2013
Departed
UGN · Waukegan, IL
Destination
5Y1 · Hessel, MI

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
55
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Seat
Left
Flight hours
1,200 total · 650 in this make and model · 30 in the last 90 days

Weather

Conditions
Visual (VMC) · Dusk
Wind
5° at 10 knots
Visibility
20 statute miles
Lowest ceiling
None
Temperature
75 °F

Docket · 7

The files NTSB released with the investigation on August 7, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.8 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.