# NTSB CEN14LA006: Piper PA-46-350P, N561C, Xenia, OH, October 9, 2013 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: October 9, 2013, 10:00 local (14:00 UTC) - Place: Xenia, OH - Coordinates: 39.691112, -83.991943 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.6911&lon=-83.9919&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report December 19, 2014 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Cincinnati FSDO - NTSB case key (mKey): 88186 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN14LA006 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88186/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88186 - Page: https://openairdocs.org/ntsb/CEN14LA006 ## Probable cause The nose landing gear failure as a result of a fatigue fracture of the engine mount nose gear actuator feet in an area detailed in a service bulletin. Contributing to the accident was maintenance personnel’s inadequate completion of the inspection specified in the service bulletin. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Landing gear system: nose/tail gear attach section](https://openairdocs.org/ntsb-findings/01023221): Aircraft › Aircraft systems · Fatigue/wear/corrosion (probable cause); cases with it: [Piper PA 46-350P, 5 cases](https://openairdocs.org/ntsb-findings/01023221/cases.md?model=7104620), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/01023221/cases.md) - [Landing gear system: nose/tail gear attach section](https://openairdocs.org/ntsb-findings/01023221): Aircraft › Aircraft systems · Inadequate inspection (probable cause); cases with it: [Piper PA 46-350P, 5 cases](https://openairdocs.org/ntsb-findings/01023221/cases.md?model=7104620), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/01023221/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Maintenance personnel (probable cause); cases with it: [Piper PA 46-350P, 8 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=7104620), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft inspection event](https://openairdocs.org/ntsb-events/050); cases with it: [Piper PA 46-350P, 2 cases](https://openairdocs.org/ntsb-events/050/sequence.md?model=7104620), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md) - [Landing-landing roll: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [Piper PA 46-350P, 19 cases](https://openairdocs.org/ntsb-events/094/sequence.md?model=7104620), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Piper PA 46-350P, 20 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7104620), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Piper PA 46-350P, 2 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=7104620), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot reported that when the nosewheel touched the runway during landing, the airplane began to pull quickly to the left. He applied right brake and pulled back on the yoke, but the airplane continued to veer off the left side of the runway. The airplane traveled about 500 feet before the nose gear collapsed back into the wheel well, and the airplane's nose and propeller impacted the ground. The postaccident examination of the airplane revealed that the engine mount in the area of the nose gear actuator feet was fractured. As a result of similar accidents, Piper Aircraft had previously issued a Mandatory Service Bulletin (SB) No. 1103D on February 2, 2011. The purpose of the 100-hour recurring inspection specified in SB 1103D was to determine if cracks had developed on the engine mount in the area of the nose gear actuator feet. The accident occurred about 81 hours of time in service after the SB 1103D was complied with. The postaccident examination of the engine mount revealed that the paint around the engine mount attach feet area was only partially removed and not as specified in the SB. A microscopic examination of the right foot of the engine mount revealed that there were fracture features indicative of fatigue progression in many areas. Although the paint removal was not as thorough as specified in the SB, the area where the fatigue fracture was located was in the area where the paint had been removed and should have been detectable during the inspection. ## Factual narrative On October 9, 2013, about 1000 eastern daylight time, a Piper PA-46-350P, N561C, was substantially damaged during landing when it departed the side of the runway and the nose wheel collapsed at the Greene County – Lewis A. Jackson Regional Airport (I19), Xenia, Ohio. The pilot and passenger on board the airplane were not injured. The airplane was owned and operated by a private individual under the provisions of the 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident, and an instrument flight plan was filed. The airplane departed Auburn, Alabama, about 0800. The pilot reported that when the nose wheel touched the runway, the airplane was pulled quickly to the left. He applied right brake and pulled back on the yoke, but the airplane continued to veer off the left side of the runway. The airplane traveled about 500 feet before the nose gear collapsed back into the wheel well, and the airplane's nose and propeller impacted the ground. The propeller blades were bent aft, and the bottom cowling, firewall, engine mounts, and nose gear were crushed upward, and bent aft. The postaccident examination of the airplane revealed that the engine mount in the area of the nose gear actuator feet was fractured. As a result of similar accidents with Piper models PA-46-310, PA-46-350P, and PA-46R-350T airplane's, Piper Aircraft issued a Mandatory Service Bulletin (SB) No. 1103S on February 2, 2011. The airplane was a Piper PA-46-350P, serial number 4636326, manufactured in 2002. The airplane's maintenance records indicated that the last annual maintenance inspection was performed on October 26, 2012, with a total aircraft time of 1,064.2 hours. The Piper SB 1103D was complied with on October 12, 2012. The inspection on October 12, 2012, was the only entry in the maintenance records that indicated that SB 1103D had been complied with. The airplane had 1,058 total hours at the time, which was 81 hours before the accident occurred. According to the SB 1103D, the inspection interval for the airplane (serial number 4636326) was: "Upon reaching 290 hours time in service on the currently installed engine mount, initial inspection to coincide with the next regularly scheduled maintenance record. Thereafter, compliance to be accomplished on a recurring basis, at a frequency interval not to exceed one hundred (100) hours time in service." The purpose of SB 1103D was to determine if cracks had developed on the engine mount in the area of the nose gear actuator attach feet. The SB stated the following inspection instructions: 1. Clean the engine mount actuator attach feet area. 2. Remove the paint or Dinitrol AV8, if the paint was previously removed and covered with Dinitrol AV8, from the inspection area (reference Figure 1). NOTE: Paint must be removed using chemical processes only. The use of abrasives or other mechanical methods to remove the paint will hide the existence of any cracks, makingan accurate inspection impossible. Use isopropyl alcohol to wipe clean the area of the engine mount where paint was removed. 3. Perform fluorescent penetrant inspection of the nose gear actuator attach feet for cracks per AC 43.13-1B, Chapter 5, Section 5. Inspect the surfaces identified in Figure 1, with specific emphasis on welded areas. 4. If a crack is discovered, the engine mount must be replaced prior to further flight (refer to Table 1). 5. If no cracks are found, continue the repetitive inspection per the compliance time above. 6. Clean the feet and apply a two-coat corrosion prevention compound (CPC) to the area where the paint was removed. This two-coat CPC consists of Dinitrol/Ardrox AV8 as a primer coating and (after the AV8 has dried) Dinitrol/Ardrox AV30 as a top coating. 7. Make an appropriate logbook entry of compliance with this Service Bulletin for each repetitive inspection. The engine mount was sent to the National Transportation Safety Board's Materials Laboratory for examination. Visual examination of the engine mount revealed that the paint around the engine mount attach feet area was only partially removed, and not in accordance to SB 1103D instructions. The microscopic examination of the right foot of the engine mount revealed that there were fracture features indicative of fatigue progression in many areas. It revealed through thickness fatigue in the foot that initiated at the toe of the weld. Additional fatigue progressed along the length of the foot tube outboard to the right edge of the foot above the forward tubes. Mechanical damage in the form of repeated fracture face re-contact and rubbing prevented identification of the fracturing mode in some areas of the engine mount foot. The examination revealed that the fatigue crack was present in the area of the engine mount where the paint had been removed for the inspection specified in SB 1103D. ## Aircraft - Registration: [N561C](https://openairdocs.org/aircraft/N561C), registered now, S/N 4636326, built 2002 (OpenAirDocs) - Reported make and model: PIPER PA-46-350P - Registry model: [Piper PA 46-350P](https://openairdocs.org/model/piper-pa-46-350p) (registry code 7104620) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 4636326 - Year built: 2002 - Airframe hours: 1150 - Engines: LYCOMING TI0-540-AEA2 350 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Greene Michael E - Registered owner: Greene Michael E - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 20, 2012, 86 hours before - Departed: AUO, Auburn, AL - Destination: I19, Xenia, OH - Flight plan: IFR - Airport: I19, Greene County Regional Airport, runway 07, 4,950 × 75 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, unknown; last flight review October 24, 2012; seat: left; restraint: 3-point; flight hours: 2,300 total, 85 in this make and model, 2,260 as pilot in command, 24 in the last 90 days, 8 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 8° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 70 °F - Observed at: I19 ## 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 20131009020049A](https://openairdocs.org/incident/20131009020049A), Oct 9, 2013: Piper PA 46-350P, Xenia, OH, Substantial damage. Prior to landing, the pilot confirmed gear was down and locked with 3 green lights. On touchdown the aircraft veered sharply left and exited the runway with… ## Docket (15 files) The files NTSB released with the investigation on November 13, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88186. 10.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410054&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Conversation - Airport Manager (item 2, .PDF, 286 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418917&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Airport%20Manager-Master.PDF - Materials Lab Report (item 3, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418915&FileExtension=.PDF&FileName=Materials%20Lab%20Report-Master.PDF - Maintenance Records Excerpts (item 4, .PDF, 592 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410057&FileExtension=.PDF&FileName=Maintenance%20Records%20Excerpts-Redacted.PDF - Piper Service Bulletin No 1130D (item 5, .PDF, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410056&FileExtension=.PDF&FileName=Piper%20Service%20Bulletin%20No%201130D-Master.PDF - FAA SAIB CE-09-13R1 (item 6, .PDF, 508 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418918&FileExtension=.PDF&FileName=FAA%20SAIB%20CE-09-13R1-Master.PDF - NTSB Safety Recommendation A-10-044 and 045 (item 7, .PDF, 193 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410055&FileExtension=.PDF&FileName=NTSB%20Safety%20Recommendation%20A-10-044%20and%20045-Master.PDF - Party Form (item 8, .PDF, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410058&FileExtension=.PDF&FileName=Party%20Form-Redacted.PDF - Wreckage Release (item 9, .PDF, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418916&FileExtension=.PDF&FileName=Wreckage%20Release-Redacted.PDF - Photo 1. View of skid marks departing runway. (item 10, .PDF, 381 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410063&FileExtension=.PDF&FileName=Photo%201.%20View%20of%20skid%20marks%20departing%20runway.-Master.PDF - Photo 2. View of aiplane lying on its nose. (item 11, .PDF, 342 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410064&FileExtension=.PDF&FileName=Photo%202.%20View%20of%20aiplane%20lying%20on%20its%20nose.-Master.PDF - Photo 3 - Engine Mount Fracture (item 12, .PDF, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418966&FileExtension=.PDF&FileName=Photo%203%20-%20Engine%20Mount%20Fracture-Master.PDF - Photo 4. View of fractured engine mount. (item 13, .PDF, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410066&FileExtension=.PDF&FileName=Photo%204.%20View%20of%20fractured%20engine%20mount.-Master.PDF - Photo 5 - Engine Mount (item 14, .PDF, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418967&FileExtension=.PDF&FileName=Photo%205%20-%20Engine%20Mount-Master.PDF - Photo 6 - Engine Mount (item 15, .PDF, 159 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418968&FileExtension=.PDF&FileName=Photo%206%20-%20Engine%20Mount-Master.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.