ERA10LA237

NTSB accident investigation · Piper PA 46-350P · Parkersburg, WV · April 16, 2010

Accident · No injuriesLimited investigationFinal report
Date
April 16, 2010, 15:20 local (19:20 UTC)
Place
Parkersburg, WV
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N779MAPiper PA 46-350P
Defining event
Landing-landing roll: Landing gear collapse
Weather
Visual (VMC) · Day
Status
Completed · report June 27, 2011
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20100416032519A
Case key
75791

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

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Probable cause

The inadequate design of the engine mount by the manufacturer, resulting in collapse of the nose landing gear. Contributing to the accident was the failure of the operator to adhere to the manufacturer's suggested engine mount inspection schedule.

Findings · 4

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 · ManufacturerAll aircraft: 35 casesProbable cause
Landing gear system: nose/tail landing gearAircraft › Aircraft systems · Fatigue/wear/corrosionAll aircraft: 185 casesProbable cause
Landing gear system: nose/tail landing gearAircraft › Aircraft systems · FailureAll aircraft: 185 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · PilotAll aircraft: 167 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, the airplane veered hard to the right when the nose gear was lowered to the runway after touchdown. The pilot attempted to maintain directional control with rudder input, but the airplane veered to the right and departed the runway. Initial examination of the airplane at the site revealed that the nose landing gear had collapsed and the attachment components between the nose landing gear actuator and the engine mount were fractured. Each of the right and left two-piece attachment feet were fractured at the nose landing gear actuator attach location. Detailed examination of the right foot showed evidence of fatigue, which covered a 0.75-inch arc and approximately 0.04 inches of the 0.06-inch wall thickness of the foot. The left foot also showed evidence of fatigue, which covered a 0.35-inch arc and was approximately 0.03 inches deep. The manufacturer had issued a series of Service Bulletins (SB 1103, with subsequent revisions A, B, and C) for PA-46-350P models that required inspections for cracks in the engine mounts in the areas of the nose landing gear actuator attachment feet. Inspections were to take place at the next regularly scheduled maintenance event, and at each 100 hours time in service or annual inspection, whichever occurred first. Records showed that SB 1103B was accomplished on the accident airplane during an annual inspection in 2007, but records of subsequent annual inspections in 2008 and 2009 showed that SB1103 was not accomplished. Previous nose gear failures and runway excursions resulted in the redesign of the original engine mount due to compliance (flexibility) in the engine mount actuator attach feet structure. This compliance issue was sometimes exasperated at various speeds, resulting in a high speed shimmy effect and subsequent uncommanded left or right turn of the nose wheel during takeoff and/or landing. The new engine mount incorporates a one piece design at the actuator attach point, eliminating the two piece feet design. The one piece design provides a less compliant structure, which prevents relative motion between the two feet in the original engine mount design. The Federal Aviation Administration did not mandate the actions outlined in SB 1103B, but compliance could have alerted the operator of any problems because the SB inspection criteria called for examinations of the engine mount in the areas where the fatigue cracks were located. Replacement of the engine mount with the new design that had one-piece nose landing gear actuator attachment feet would have relieved the operator of the manufacturer's repetitive inspection requirement, but because the accident airplane still had the welded two-piece attachment feet it was subject to the repetitive inspection per the service bulletin.

Factual narrative

On April 16, 2010, about 1520 eastern daylight time, a Piper PA 46-350P, N779MA, was substantially damaged when the nose landing gear collapsed upon landing at Parkersburg, West Virginia (PKB). The airplane was operated by P & C Aviation LLC. The commercial pilot and one passenger were not injured. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the business flight conducted under the provisions of 14 Code of Federal Regulations Part 91. The pilot reported that he was landing on runway 21 at PKB. The main landing gear touched down normally and as the nose gear was lowered to the runway, the airplane veered hard to the right. The pilot attempted to maintain directional control with full left rudder, but as the airplane slowed and rudder authority became less effective, the airplane departed the right side of the runway into the grass. An inspector from the Federal Aviation Administration (FAA) responded to the accident site and examined the wreckage. The structure surrounding the nose gear and engine mount was substantially damaged. A cursory examination of the nose gear revealed that the attachment components between the nose landing gear actuator and the engine mount were fractured. Photographs were taken of the affected components and the airplane was moved to a hangar and secured. The engine mount was subsequently disassembled and the fractured sections were removed and sent to the NTSB Materials Laboratory for examination and analysis. NTSB Materials Laboratory Examination / Findings: The engine mount was of a welded tubular construction, and the attachment feet were positioned at the aft end of the engine mount. Each attachment foot was constructed by welding a tube to a disk. The welded attachment feet on the airplane were of an older design (Newer attachment feet have since been redesigned to be machined from a single solid piece.). Each attachment foot was welded to three support tubes that extended forward and down and were welded to the engine mount. The right attachment foot was completely separated from the support tubes by fractures. The left attachment foot was separated from two of the support tubes by fractures, and one of the tubes supporting the left attachment foot was bent. Along the inner edge of the right attachment foot where the foot was welded to its center support tube, the fracture surface was smooth and retained curving crack arrest markings consistent with fatigue cracking emanating from multiple origins along the toe of the weld joining the foot and the support tube. The fatigue cracking propagated primarily through the parent metal of the attachment foot. The fatigue cracking extended over an arc length of approximately 0.75 inch, and penetrated at least 0.04 inch through the estimated 0.06-inch wall thickness of the foot. There was significant oxidation of the fracture surface in the area of fatigue cracking on the right attachment foot. No weldingdeficiencies (such as incomplete penetration or incomplete fusion) were observed in the welds joining the right attachment foot to the support tubes. Along the lower inner edge of the left attachment foot where the foot was welded to its center support tube, the fracture surface retained several regions that were smooth and had curving crack arrest markings consistent with fatigue cracking emanating from multiple origins along the weld joining the foot and the support tube. The fatigue cracking propagated through the parent metal of the center support tube and in the weld metal between the center and bottom support tubes. The area of fatigue cracking extended over a length of approximately 0.35 inch, and penetrated a maximum of approximately 0.03 inch deep. There was very little oxidation of the fracture surfaces in the area of fatigue cracking on the left attachment foot. No welding deficiencies (such as incomplete penetration or incomplete fusion) were observed in the welds joining the left attachment foot to the support tubes. A factual report (Materials Laboratory Factual Report No. 10-102) describing the detailed examination of the engine mount components is available in the public docket of supporting documentation for this accident investigation. Service Bulletin / Engine Mount Design Information: Beginning in April 2002, Piper issued a series of mandatory Service Bulletins (SB 1103, with subsequent revisions A, B and C) for PA-46-350P models, requiring inspections for cracks in the engine mounts in the areas of the nose landing gear actuator attachment feet. Inspections were to take place at the next regularly scheduled maintenance event, and at each 100 hours time in service or annual inspection, whichever occurred first. Replacement of the engine mount with the new design that had one-piece nose landing gear actuator attachment feet would have relieved the repetitive inspection requirement, but since the accident airplane still had the welded two-piece attachment feet, it was subject to repetitive inspection per the service bulletins. Maintenance Information: An examination of the airplane maintenance logbooks revealed that Piper SB 1103B was accomplished during an annual inspection on May 4, 2007. An examination of the logbook entries for the subsequent annual inspections accomplished on May 1, 2008 and June 5, 2009 revealed that Piper SB1103 was not accomplished. The operator did not provide a reason for why the inspections were not accomplished after May 4, 2007.

Aircraft

Registration
N779MA
Reported as
Piper PA 46-350P
Category
Airplane
Serial number
4636279
Airframe hours
1,670
Engine
Lycoming TIO 540 SER, 350 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Operator
P & C Aviation LLC
Registered owner
P & C Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 8, 2009 · 124 hours before
Departed
CLT · Charlotte, NC
Destination
PKB · Parkersburg, WV
Flight plan
IFR
Airport
PKB · Mid-Ohio Valley Regional, runway 21, 6,781 × 150 ft, asphalt

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
52
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
July 23, 2009
Seat
Left
Flight hours
1,450 total · 281 in this make and model · 1,263 as pilot in command · 59 in the last 90 days · 25 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 14 knots, gusting 30
Visibility
6 statute miles
Lowest ceiling
6,000 ft broken
Temperature
68 °F, dew point 55 °F
Altimeter
29.94 inHg
Observed at
PKB

Docket · 5

The files NTSB released with the investigation on April 15, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.9 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.