# NTSB CEN14LA196: Piper PA 46-350P, N1972M, West Chicago, IL, April 11, 2014 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: April 11, 2014, 16:07 local (21:07 UTC) - Place: West Chicago, IL - Coordinates: 41.908889, -88.249168 - Nearby events: https://openairdocs.org/map.md?lat=41.9089&lon=-88.2492&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Aircraft structural failure](https://openairdocs.org/ntsb-events/337) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report April 20, 2016 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA, Piper Aircraft - NTSB case key (mKey): 89051 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN14LA196 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89051/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89051 - Page: https://openairdocs.org/ntsb/CEN14LA196 ## Probable cause The failure of the nose gear actuator attachment to the engine mount due to overstress, which resulted in the loss of directional control during landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Landing gear system: nose/tail landing gear](https://openairdocs.org/ntsb-findings/01023220): Aircraft › Aircraft systems · Malfunction (probable cause); cases with it: [Piper PA 46-350P, 4 cases](https://openairdocs.org/ntsb-findings/01023220/cases.md?model=7104620), [All aircraft, 185 cases](https://openairdocs.org/ntsb-findings/01023220/cases.md) - [Power plant: mounts](https://openairdocs.org/ntsb-findings/01057120): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA 46-350P, 2 cases](https://openairdocs.org/ntsb-findings/01057120/cases.md?model=7104620), [All aircraft, 5 cases](https://openairdocs.org/ntsb-findings/01057120/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Piper PA 46-350P, 11 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=7104620), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot; cases with it: [Piper PA 46-350P, 40 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7104620), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Aircraft structural failure](https://openairdocs.org/ntsb-events/337) (defining event); cases with it: [Piper PA 46-350P, 4 cases](https://openairdocs.org/ntsb-events/337/sequence.md?model=7104620), [All aircraft, 290 cases](https://openairdocs.org/ntsb-events/337/sequence.md) - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Piper PA 46-350P, 14 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7104620), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA 46-350P, 40 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7104620), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/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) ## Analysis The commercial pilot was conducting a business flight and was preparing to land the airplane. He reported that, during the landing approach, he lowered the landing gear, which resulted in a gear down-and-locked indication. He subsequently made a smooth landing, but as soon as the nose gear touched down, the airplane "yanked severely to the left." He attempted to maintain directional control, but the airplane exited the left side of the runway into grass, the right wing contacted an airport sign, and the landing gear collapsed. A postaccident examination revealed that the nose gear actuator attachment to the engine mount was fractured in two places. A metallurgical examination revealed that the fracture surfaces and deformation patterns were indicative of overstress separations at both locations. No preexisting cracking was noted. The investigation could not determine whether the overstress damage occurred during the accident landing or previous landings. The airplane manufacturer had previously issued a service bulletin (SB), which recommended that an initial inspection of the engine mount for cracks in the area of the nose gear actuator attachment be accomplished at 740 hours time in service (TIS). However, the airplane only had 550 hours TIS at the time of the accident; therefore, it had not undergone the initial inspection recommended by the SB. Following the accident, the manufacturer reduced the initial inspection time to 200 hours TIS and redesigned the engine mount. ## Factual narrative On April 11, 2014, about 1607 central daylight time, N1972M, a Piper Mirage PA-46-350P airplane, experienced a landing gear collapse following a loss of directional control on landing at the DuPage County Airport (DPA), West Chicago, Illinois. The commercial pilot and passenger were not injured. The airplane received substantial damage to the firewall and wings. The airplane was registered to General Leasing of Michigan LLC and was operated by the pilot/owner as a 14 Code of Federal Regulations Part 91 business flight. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The flight originated from the DuPont-Lapeer Airport (D95), Lapeer, Michigan, about 1430. The pilot stated that he received a gear down and locked indication when he lowered the landing gear and during the approach. He stated the landing was smooth and as soon as the nose gear touched down, the airplane "yanked severely to the left." He attempted to maintain control, but the airplane ultimately traveled into the grass off the left side of the runway. The right wing contacted an airport sign and the landing gear collapsed. A postaccident examination revealed that the nose gear actuator attachment was fractured in two places. Further examination revealed that the fracture surfaces and deformation pattern were indicative of overstress separations at both locations. No preexisting cracking was noted. The nose gear position switch is located on the nose gear actuator. As the nose gear retracts, the steering linkage separates from the gear so that movement of the rudder pedals does not move the position of the nose gear. The nose gear is designed to rotate 90 degrees to stow in the retracted position. The nose gear actuator is bolted to the lower aft engine mount, which is constructed of welded tubes. The nose gear actuator extends from the engine mount and attaches to the nose landing gear. Piper Aircraft Service Bulletin 1103D dated February 2, 2011, was current at the time of the accident. The service bulletin addressed engine mount inspection intervals for PA-46-310P, PA-46-350P and PA-46-350T airplanes as a result of several accidents and incidents where cracks developed on the engine mount in the area of the nose gear actuator attachment. For the accident airplane, the service bulletin required the first engine mount inspection to be accomplished at 740 hours of time in service, and thereafter at a frequency not to exceed 100 hours of time in service. The accident airplane had 550 hours of time in service when the accident occurred, thus it was 190 hours below the initial inspection time requirement. On June 5, 2014, subsequent to the accident, Piper Aircraft updated the service bulletin reducing the initial inspection time to 200 hours of time in service and thereafter at intervals not to exceed 100 hours of time in service. The service bulletin also stated that Piper Aircraft had redesigned the engine mount and ifthe new engine mount was installed, the inspections could be eliminated. On April 8, 2010 the National Transportation Safety Board had issued Safety Recommendation A-10-44 and -45, suggesting that the Federal Aviation Administration: 1) require repetitive inspections for fatigue cracks on all PA-46-310 and -350P airplanes, and 2) require Piper Aircraft to redesign the PA-46-310 and -350P engine mounts so that they would not be susceptible to fatigue cracking. ## Aircraft - Registration: [N1972M](https://openairdocs.org/aircraft/N1972M), registered now, S/N 4636631, built 2014 (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 7104618) (OpenAirDocs) - Registry engine: [Lycoming TIO-540-AE2A](https://openairdocs.org/engine/lycoming-tio-540-ae2a) (registry code 40999, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 4636524 - Year built: 2012 - Airframe hours: 537.5 - Engines: LYCOMING TIO-540-AE2A 350 horsepower reciprocating - Damage: Substantial damage - Fire: Unknown - Flight: Business, Part 91 - Operator: General Leasing Of Michigan LLC - Registered owner: General Leasing Of Michigan LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 17, 2014, 46 hours before - Departed: D95, Lapeer, MI - Destination: DPA, West Chicago, IL - Flight plan: IFR - Airport: DPA, DuPage County Airport, runway 20R, 7,571 × 100 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: none; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: left; restraint: 3-point; flight hours: 640 total, 357 in this make and model, 604 as pilot in command, 3 in the last 90 days, 3 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 14 knots, gusting 20 - Visibility: 10 statute miles - Lowest ceiling: 10,000 ft broken - Observed at: DPA ## 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 20140411004089A](https://openairdocs.org/incident/20140411004089A), Apr 11, 2014: Piper PA 46-350P, West Chicago, IL, Substantial damage. Aircraft attempted normal landing runway 20R. The main gear touched normally, when the nose gear touched the runway the aircraft veered left, the pilot… ## Docket (9 files) The files NTSB released with the investigation on February 29, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89051. 3.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 889 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437100&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Materials Laboratory Factual Report 14-031 Engine Mount (item 2, .PDF, 1 photo, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437101&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report%2014-031%20Engine%20Mount-Master.PDF - Record of Conversations (item 3, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437102&FileExtension=.PDF&FileName=Record%20of%20Conversations-Master.PDF - Piper Aircraft Service Bulletins 1103D and 1103F (item 4, .PDF, 441 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437103&FileExtension=.PDF&FileName=Piper%20Aircraft%20Service%20Bulletins%201103D%20and%201103F-Master.PDF - Maintenance Manual (Excerpts) (item 5, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437104&FileExtension=.PDF&FileName=Maintenance%20Manual%20(Excerpts)-Master.PDF - Annual Inspection Entries (item 6, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437105&FileExtension=.PDF&FileName=Annual%20Inspection%20Entries-Master.PDF - NTSB Recommendation A-10-44 and -45 (item 7, .PDF, 275 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437106&FileExtension=.PDF&FileName=NTSB%20Recommendation%20A-10-44%20and%20-45-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 8, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437107&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 9, .PDF, 179 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437108&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-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.