DEN07IA066

NTSB incident investigation · Diamond Aircraft Industries DA-20-C1 · Pueblo, CO · March 6, 2007

Incident · No injuriesIncident investigationFinal report
Date
March 6, 2007, 09:00 local (16:00 UTC)
Place
Pueblo, CO
Injuries
2 uninjured
Damage
No damage
Phase of flight
Maneuvering
Aircraft
N921DADiamond Aircraft Industries DA-20-C1
Weather
Visual (VMC) · Day
Status
Completed · report March 31, 2008
Report
Approved by Office Director
Parties
Transport Canada, Diamond Aircraft Industries - Canada, Transportation Safety Board of Canada
FAA report
20070306003069I
Case key
65382

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

The failure of the horizontal stabilizer forward bracket bolts due to insufficent preload during factory installation.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionManeuvering
Horizontal stabilizer attachment - separation
Miscellaneous,bolt/nut/fastener/clamp/spring - failure,totalCause
Maintenance,installation - inaccurateManufacturerCause
Miscellaneous,bolt/nut/fastener/clamp/spring - fatigueCause

Analysis

The flight instructor reported that abnormal nose-up trim was required while in flight. The flight concluded without additional or further incidence. After the training flight a 2 to 3-inch gap between the horizontal and vertical stabilizer was noted. Examination of the airplane revealed two bolts, securing the front horizontal stabilizer mounting bracket to the vertical stabilizer, had failed. Examination of the bolts revealed failure due to undetected fatigue. On the failed bolts, the sizes of the final overstress regions were very small indicating that peak and mean loads on the bolts were also small. This would indicate that only a small or marginal preload was present on the bolts. Insufficient preload could be the result of low installation torque or the loss of preload during service. The off center wear on the washers suggests that the fastened surfaces may not have been in alignment allowing the installation preload to quickly degrade.

Factual narrative

On March 6, 2007, approximately 0900 mountain standard time, a Diamond Aircraft Industries DA-20-C1, N921DA, owned and operated by Doss Aviation Incorporated, sustained a partial forward horizontal stabilizer separation while in flight near Pueblo Memorial Airport (PUB), Pueblo, Colorado. Visual meteorological conditions prevailed at the time of the occurrence. The instructional flight was being conducted under the provisions of Title 14 Code of Federal Regulations Part 91 without a flight plan. The student pilot and commercial certificated flight instructor were not injured. The local flight originated at PUB at 0800.

According to the flight school, the training flight included maneuvers such as steep turns, power on stalls, slow flight, and forward slips to a landing. The airplane returned to PUB, at which time the flight instructor took control of the airplane and noted "abnormal nose-up trim was required." The training flight continued with an additional 5 landings, as "there were no excessive flight control inputs required to safely fly" the airplane. The flight concluded without additional or further incident.

After the training flight, a 2 to 3 inch gap between the horizontal and vertical stabilizer was noted by the operator. Examination of the airplane revealed that the two bolts securing the front mounting bracket of the horizontal stabilizer to the vertical stabilizer had separated. The fractured bolts including the nut side of one bolt and the washers were sent to the National Transportation Safety Board Materials Laboratory, in Washington, D.C., for further examination. In addition, the forward bracket bolts from two other similar airplanes owned by Doss Aviation (N920DA and N922DA) were also forwarded to the NTSB lab for examination.

According to the Materials Laboratory Factual Report, both bolts had fractured through the threaded portion of the shank. The left bolt contained multiple facture surfaces that intersected the first and second full thread roots from the head side of the bolt. Examination of the fracture intersections indicated the transverse fracture at the second thread was the primary fracture with the slanted fracture from the first thread being the secondary fracture. The nut side of the bolt exhibited a smooth, finely textured fracture surface that contained ratchet marks and curved crack arrest lines indicative of fatigue cracking initiating in the thread root radius with propagation across the bolt section. The fatigue propagated completely through the bolt with no discernable overstress region. Assembly (torque) paint was noted on the nut and adjacent bolt threads.

Visual examination of the washers revealed that one of the washers exhibited fretting and wear patterns that matched those on the washer face of the nut from the left bolt. On the washer face of the nut, the fretting was predominately adjacent to the fatigue region on the bolt.

The right bolt had a single fracture plane intersecting the second full thread root from the bolt head. The right bolt fracture was very similar to the transverse fracture of the left bolt showing features consistent with fatigue initiation in the thread root. Propagation was directly across the cross section with a small overstress region opposite the fatigue initiation region.

No damage or abnormalities were noted in the thread roots at the fatigue initiation regions of either fractured bolt. Examination of the forward bracket bolts from N920DA and N922DA revealed no anomalies.

According to the Diamond Aircraft parts manual for the horizontal stabilizer, part number AN3-11A identifies the two hex bolts. The bolts are marked with a raised "X" indicating non-corrosion resistant steel bolts and raised letters "AFC" denoting the bolt manufacturer.

According to manufacturing procedures given by Diamond Aircraft, the installation of these bolts occurs prior to the post cure of the composite structure. Following the post cure, a quality insurance inspector checks the torque and applies the witness paint. These bolts are to be torqued to a value of 20 to 25 inch pounds. Diamond reported that there is no torque for field maintenance, as this connection is not normally serviced in the field.

According to Doss Aviation, this airplane had 189 hours total time. A review of the maintenance logs revealed no discrepancies or maintenance on the horizontal stabilizer or brackets.

The Transportation Safety Board (TSB) of Canada provided an accredited representative for the investigation. Diamond Aircraft Industries and Transport Canada were the technical advisors to TSB Canada.

Aircraft

Registration
N921DA
Reported as
Diamond Aircraft Industries DA-20-C1
Category
Airplane
Serial number
C0395
Airframe hours
189
Engine
Teledyne Continental IO-240-B, 125 horsepower, reciprocating
Damage
No damage
Flight
Instructional · Part 91
Registered owner
Doss Aviation Inc.
Airworthiness certificate
Standard, Utility
Last inspection
100 hour · February 1, 2007
Departed
KPUB · Pueblo, CO
Destination
KPUB · Pueblo, CO
Airport
PUB · Pueblo Memorial, runway 26L, 4,073 × 75 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
29
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
September 1, 2006
Seat
Left
Flight hours
1,250 total · 600 in this make and model · 1,200 as pilot in command · 60 in the last 90 days · 30 in the last 30 days · 1 in the last 24 hours
Role
Student pilot
Age
24
Injuries
None
Certificate
Student
Medical
Class 3, Valid Medical--no waivers/lim.
Last flight review
September 1, 2006
Seat
Right
Flight hours
58 total · 5 in this make and model · 14 as pilot in command · 5 in the last 90 days · 5 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
43 °F, dew point 7 °F
Altimeter
30.14 inHg
Observed at
KPUB, 1 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.