ERA09LA471

NTSB accident investigation · Piper PA-46-350P · Sanford, FL · August 16, 2009

Accident · No injuriesLimited investigationFinal report
Date
August 16, 2009, 11:30 local (15:30 UTC)
Place
Sanford, FL
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N548CPiper PA-46-350P
Defining event
Landing-flare/touchdown: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed · report December 20, 2010
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Piper Aircraft, Inc, FAA / FSDO
Safety recommendations
Yes
Case key
74564

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 fatigue cracking at the point the nose landing gear actuator attaches to the mount resulting in separation of the actuator and partial collapse of the nose landing gear. Contributing to the accident was the lack of specific inspection guidance for scheduled maintenance to find and/or identify fatigue cracking in the welded actuator attach points of the newly designed mounts.

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.

Design: equipment designOrganizational issues › Development · ManufacturerPiper PA 46-350P: 1 caseAll aircraft: 35 casesProbable cause
Landing gear system: nose/tail gear attach sectionAircraft › Aircraft systems · Related maintenance infoPiper PA 46-350P: 5 casesAll aircraft: 29 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

During landing, as the nose landing gear wheel made contact with the runway, the airplane veered suddenly to the left and exited the runway, incurring substantial damage, before coming to a stop in the adjacent grass area. Examination of the airplane’s nose gear assembly revealed the separation of the nose gear actuator attachment weld tube area (foot) of the motor mount. The metallurgical examination of fractured surface revealed fatigue crack emanating from multiple origins at the exterior of the joint where the attachment foot was welded to the support tube. The motor mount was a new design from the manufacturer which was to eliminate the concerns of fatigue separation of the weld in the foot area which was a problem with the old design motor mounts. The airplane had an annual inspection 36 flight hours prior to the accident. The new design motor mount does not have any specific inspection guidance during scheduled maintenance for identifying fatigue cracking in the actuator attach points. The old design motor mounts had detailed inspection instructions to detect fatigue cracking in the welds of the foot areas.

Factual narrative

On August 16, 2009, at 1130 eastern daylight time, a Piper, PA-46-350P, N548C, had the nose landing gear collapse during landing at the Orlando-Sanford International Airport, Orlando, Florida. The pilot and passenger were not injured, and the airplane incurred substantial damage. Visual meteorological conditions prevailed and no flight plan was filed. The airplane was operated by a private individual, under the provisions of Title 14 Code of Federal Regulations Part 91, as a personal flight. The pilot stated to the responding Federal Aviation Administration (FAA) inspector that he performed a visual approach to runway 9 left; the wind was from the 140 degrees and at 10 knots (kts). He was cleared to land by the airport traffic controller and confirmed the three green lights for down and locked on the landing gear position. The main wheels touched down at an estimated speed of 85 kts with full flaps extended. As the nose wheel touched the runway, immediately and without warning the nose of the airplane veered left. The airplane swerved left, off the runway, skidding onto the grass. The propeller struck the ground before the airplane came to a stop. The pilot shut down the engine and secured the airplane before he and his passenger disembarked the airplane. A post recovery examination of the airplane revealed the right side welded section, on the engine mount, where the nose gear actuator attaches, had separated. The component was removed and retained by the National Transportation Safety Board (NTSB) for further analysis. NTSB materials laboratory examination of the fractured surface revealed a fatigue crack emanating from multiple origins at the exterior of the joint where the attachment foot was welded to the support tube. At the time of the accident, the airplane was 8 years old and had accumulated 711 flight hours with 878 cycles since new. The accident airplane was a Piper PA-46-350P, Malibu Mirage, serial number 4636322, manufactured in 2001, and issued a Standard Airworthiness Certificate in the Normal Category. The airplane was powered by a Textron Lycoming TIO-540-AE2A, 350 horse powered engine. The airplane was under the Piper Aircraft Inc., Piper Malibu Maintenance Program. The airplane’s last annual inspection was performed on February 16, 2009, at 675 total hours. The last unscheduled maintenance performed was on July 27, 2009, at 697 total hours. The Piper Aircraft Inc., Maintenance Inspection, for the PA-46 350P, 100 Hour interval Inspection, item 40, instructs to “inspect engine mount for cracks, corrosion and loose mounting bolts (See 100 hour Engine Mount Inspection, 71-20-00)”, which calls out for Item 1, Engine Mount, A. Inspection, (1) 100 Hour “In Serial Numbers 4636001 through 4636319 with the original factory-installed engine mount, each 100 hours time-in-service.” The 100 hour inspection is inclusive of the annual inspection. The steps instruct to remove the paint from the weld areas for the actuator nose landing gearattachment section (foot) and to conduct a visual, and to use a” liquid penetrant inspection”, inspection for cracks. The motor mount crack inspection was not applicable to the accident airplane by serial number (4636322). The airplane was manufactured with a newly designed motor mount. The airplane’s manufacturer has issued a series of service bulletins (SB) addressing the inspection guidance on the motor mount cracking concerns with the older design motor mount, which are repetitive until a new design motor mount is installed. The manufacturer has developed the new motor mount to eliminate the cracking concerns of the older design motor mounts. The new design motor mount does not have any special inspection guide lines or SB for specific inspection instruction for the area of known cracking. The NTSB has investigated two accidents involving failure of the nose gear actuator attach foot and one case in which maintenance discovered failure of the attach foot on newly designed Piper PA-46-350P motor mounts. The investigations found fatigue cracks of the weld joints at the nose gear actuator attachment foot support tube locations.

Aircraft

Registration
N548C
Reported as
Piper PA-46-350P
Category
Airplane
Serial number
4636322
Airframe hours
711
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 16, 2009 · 36 hours before
Departed
KJKA · Gulf Shores, AL
Destination
KSFB · Sanford, FL
Airport
KSFB · Orlando-Sanford International, runway 09L, 9,600 × 150 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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
60
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Seat
Left
Flight hours
2,029 total · 711 in this make and model · 1,872 as pilot in command · 42 in the last 90 days · 16 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
120° at 12 knots, gusting 16
Visibility
10 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 72 °F
Altimeter
30.12 inHg
Observed at
SFB

Docket · 16

The files NTSB released with the investigation on September 1, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.8 MB in all.

Other investigations on N548C · 1

Matched to the same aircraft by N-number and date.