CEN23LA172

NTSB accident investigation · Piper PA-34-200 · Coldspring, TX · May 3, 2023

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
May 3, 2023, 13:29 local (18:29 UTC)
Place
Coldspring, TX · 8mi West of Cold Spring, TA and 3 mi north of SH150
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N28HEPiper PA-34-200
Defining event
Maneuvering: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA
FAA report
20230503011539A
Case key
107813

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 stabilator trim rod assembly separated from the stabilator link assembly due to a missing connecting bolt, which resulted in the pilot’s inability to maintain pitch control of the airplane.

Findings · 1

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.

Flight control system: elevator tab control systemAircraft › Aircraft systems · Not installed/availablePiper PA-34-200: 1 caseAll aircraft: 37 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

According to the pilot examiner, following steep turn maneuvers, they heard a loud “pop” from the tail of the airplane, the nose abruptly pitched up, and the airplane entered an accelerated stall. He took control of the airplane and added power to recover from the stall, at which time they heard another loud bang and the nose of the airplane pitched abruptly down. He reduced power to idle, there was another bang, and once again, the airplane pitched up uncontrollably. This time he did not add power and the nose of the airplane pitched down, but not as severely and he was able to use the engine power to dampen the pitch oscillations. Unable to maintain full control of the airplane, he elected for an emergency, off-airport landing. The airplane contacted trees while on approach to the field. The airplane landed hard, bounced, and slid through a rough, muddy field, which resulted in substantial damage to both wings, the fuselage, and empennage. A postaccident examination revealed that the bolt that connects the stabilator trim rod assembly to the stabilator link assembly was missing and not located. Since the bolt was not recovered, the reason for the separation could not be determined. Without being able to determine the reason for the separation, the flight school proactively inspected all same model airplanes in their fleet and replaced the bolt on each of them.

Factual narrative

On May 3, 2023, about 1329 central daylight time, a Piper PA-34-200 airplane, N28HE, sustained substantial damage when it was involved in an accident near Coldspring, Texas. The pilot examiner and flight instructor sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 pilot certification flight. According to the pilot examiner, following steep turn maneuvers, they heard a “loud metallic bang” from the tail of the airplane and the control yoke abruptly went to the full nose-up position. He stated the nose of the airplane pitched up rapidly, and the stall warning went off as they entered an accelerated stall. He took control of the airplane and applied full power to recover from the stall, at which time they heard another loud bang from the tail and the nose of the airplane pitched abruptly down. He reduced power to idle, there was another bang, and once again the airplane pitched up uncontrollably. This time he did not add power and the nose of the airplane pitched down, but not as severely and he was able to use the engine power to dampen the pitch oscillations. Unable to maintain full control of the airplane, he elected for an emergency, off-airport landing. While on the final approach, as the airplane clipped the tops of trees, the pilot examiner pulled the mixture controls to cutoff. Upon touchdown, the airplane bounced then slid through a rough, muddy field, which resulted in substantial damage to both wings, the fuselage, and empennage. A postaccident examination revealed that the bolt (item 49 in figure 1) which connects the stabilator trim rod assembly (item 12) to the stabilator link assembly (item 13) was missing. (Figure 2) Figure 1. Illustrated Parts Catalog (Part Nos. 753-816) Figure 2. Photo of the stabilator trim assembly (Photo courtesy of the FAA) A review of applicable maintenance records revealed two maintenance logbook entries for the elevator trim wheel cable becoming unspooled, the first on March 14, 2023, and the second on March 23, 2023. After each repair, a functional check flight was accomplished with no discrepancies noted. In an interview with the mechanic from the March 23 repair, he stated that he did not disconnect or otherwise perform maintenance on the affected control rod or linkage. The pilot examiner stated that during the preflight inspection, no anomalies were noted with the trim linkage assembly. Following the accident, the flight school inspected all PA-34 airplanes in their fleet and replaced the affected bolt on each airplane.

Aircraft

Registration
N28HE
Reported as
Piper PA-34-200
Category
Airplane
Serial number
34-7350278
Built
1973
Engines
Lycoming IO360, 200 horsepower, reciprocatingLycoming LIO-360, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Wings Over Texas Holdings LLC
Registered owner
Wings Over Texas Holdings LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · February 7, 2023
Departed
KCXO · Conroe, TX
Airport
NA
Equipment
Stall warning system, ADS-B

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
69
Injuries
Serious
Certificates
Airline transport, Flight instructor
Airplane ratings
Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Waiver time limited special
Seat
Right
Restraint
3-point
Role
Pilot
Age
21
Injuries
Serious
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
August 5, 2022
Seat
Left
Restraint
3-point

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 8 knots
Visibility
10 statute miles
Temperature
82 °F, dew point 64 °F
Altimeter
29.96 inHg
Observed at
KCXO, 5 nm away
METAR
KCXO 031753Z 10008KT 1OSM FEW040 28/18 A2996 RMKAO2 SLPI41 T02780178 10278 20167 58017

Docket · 4

The files NTSB released with the investigation on October 5, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 358 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.