# NTSB ERA13IA326: Piper PA-34, N767PE, Palm Coast, FL, July 17, 2013 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: July 17, 2013, 13:00 local (17:00 UTC) - Place: Palm Coast, FL - Coordinates: 29.601943, -81.208335 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.6019&lon=-81.2083&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report February 3, 2016 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 87517 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA13IA326 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/87517/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=87517 - Page: https://openairdocs.org/ntsb/ERA13IA326 ## Probable cause The installation of an incorrect rudder trim tab control rod by unknown maintenance personnel, which resulted in the rod failing in flight due to overload and subsequent uncontrolled rudder oscillations. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Misc hardware](https://openairdocs.org/ntsb-findings/01071400): Aircraft › Fluids/misc hardware · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-34-200, 1 case](https://openairdocs.org/ntsb-findings/01071400/cases.md?model=7103405), [All aircraft, 41 cases](https://openairdocs.org/ntsb-findings/01071400/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Maintenance personnel (probable cause); cases with it: [Piper PA-34-200, 3 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=7103405), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-34-200, 2 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=7103405), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Maintenance/inspections](https://openairdocs.org/ntsb-findings/01010500): Aircraft › Aircraft handling/service · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-34-200, 1 case](https://openairdocs.org/ntsb-findings/01010500/cases.md?model=7103405), [All aircraft, 103 cases](https://openairdocs.org/ntsb-findings/01010500/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Piper PA-34-200, 2 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=7103405), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Maneuvering: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) (defining event); cases with it: [Piper PA-34-200, 2 cases](https://openairdocs.org/ntsb-events/333/sequence.md?model=7103405), [All aircraft, 410 cases](https://openairdocs.org/ntsb-events/333/sequence.md) ## Analysis The pilot receiving instruction was recovering the airplane from a demonstrated minimum control airspeed condition. According to the flight instructor, the airplane was initially about 5,000 ft in a "clean" configuration. Both pilots then felt two "kicks" in the rudder system, which they then verbally confirmed to each other did not result from either of them making inputs. The pilot receiving instruction then heard a "snap," and the rudder pedals began to "pump" full deflection right and left. Subsequently, the flight instructor took control of the airplane and found that neither applying full rudder nor using both feet on the rudder neutralized the deflections. Even with both pilots trying to neutralize the rudders, the deflections continued. The flight instructor subsequently diverted the airplane to a nearby airport and landed it uneventfully. During the on-scene examination, the rudder trim tab control rod was found fractured near the trim tab end. The control rod was replaced, and, during subsequent flights, no further rudder anomalies occurred. Metallurgical examination of the rod revealed that it had failed in overload, and no evidence of fatigue or corrosion was found. Further examination revealed that the rudder trim control rod was composed of a low-alloy, 1000-series carbon steel. An airplane manufacturer representative indicated that the rod should have been composed of a higher grade, 4000-series steel. The airplane was manufactured in 1972, acquired by the current owner in 2005, and had 11,575 hours of operation at the time of the incident. It could not be determined when or by whom the rod was installed on the airplane; it was not installed during the airplane's current ownership. ## Factual narrative On July 17, 2013, about 1300 eastern daylight time, a Piper PA-34-200, N767PE, operated by Phoenix East Aviation (PEA), experienced in-flight tail vibrations near Palm Coast, Florida. The airplane subsequently landed without structural damage at Flagler County Airport (XFL), Palm Coast, Florida. The flight instructor and the private pilot under multi-engine instruction were not injured. Visual meteorological conditions prevailed during the local instructional flight, which departed Daytona Beach International Airport (DAB), Daytona Beach, Florida, and was operating under the provisions of 14 Code of Federal Regulations Part 91. According to the flight instructor, the airplane was initially about 5,000 feet in a "clean" configuration with the pilot under instruction recovering from minimum control airspeed condition. There were then two "kicks" in the rudder system, which the pilots confirmed did not come from either of them. The pilot under instruction then heard a "snap", and the rudder pedals began to "pump" full deflection both right and left. The flight instructor took control of the airplane and found that neither the application of full rudder nor the use of both feet to neutralize the deflections had any effect. Even with both pilots trying to neutralize the rudders, they could not overcome the deflections. The flight instructor diverted the airplane to XFL, subsequently landing with 25-degree flaps without further incident. There was minimum rudder control during the approach, with the rudder pedals still pumping back and forth throughout the landing. Once on the ground, full rudder control was again available. On the ground, the rudder trim tab control rod was found to be fractured near the trim tab end. The control rod was replaced, and subsequent flights revealed no further rudder anomalies. Remnants of the control rod end were forwarded to the NTSB for further examination. According to the Materials Laboratory Factual Report, "the overall fracture morphology was cone-shaped, concave toward the bearing head. The thread adjacent the fracture surface exhibited some local deformation….The four thread roots adjacent the fracture surface exhibited cracking along the roots." In addition, "both halves of the fractured rod end exhibited smearing damage consistent with post-failure damage. The smearing damage on the bearing head portion was located on opposite sides of the part, evident as mirrored damage patterns positions 180° apart. Similar damage was noted on the fractured side of the threaded shaft….On the threaded shaft, most of the outer portions of the fracture surface had been obliterated." The bearing head portion of the fractured shaft was subsequently ultrasonically cleaned to remove surface oxidation (rust). The fracture surface was then inspected using a scanning electron microscope (SEM). The fracture surface was "rough and tortuous with high peaks and valleys," but "generally concave downward." The fracture morphology wasconsistent with "dimple rupture" with no other types of fractures noted. "The presence of only dimple rupture fracture morphology, the general cup-and-cone shape of the mating fracture surfaces and the secondary thread root cracks are consistent with failure from overstress. The dimple rupture shape and local deformation of the part are consistent with overstress in tension. No indications of other failure modes, such as fatigue or pre-fracture corrosion, were observed." The chemical composition of the part was inspected using energy dispersive x-ray spectroscopy (EDS) and found to be consistent with low-alloy carbon steel, a 1000-series steel. According to an air safety investigator with Piper Aircraft, the rod should have been "a 4130 gr1 type material," a 4000-series steel. According to the PEA Director of Safety, a review of aircraft logbooks confirmed that PEA had not changed the rod since acquiring the airplane, which Federal Aviation Administration records indicated occurred in 2005. The airplane was manufactured in 1972 and had a reported total time of 11,575 hours at the time of the incident. ## Aircraft - Registration: [N767PE](https://openairdocs.org/aircraft/N767PE), registered now, S/N 34-7350042, built 1972 (OpenAirDocs) - Reported make and model: PIPER PA-34 (200) - Registry model: [Piper PA-34-200](https://openairdocs.org/model/piper-pa-34-200) (registry code 7103405) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 34-7350042 - Airframe hours: 11575 - Engines: LYCOMING I0360 SER 180 horsepower reciprocating; LYCOMING IO360 SER 180 horsepower reciprocating - Damage: No damage - Flight: Instructional, Part 91 - Operator: Phoenix East Aviation, LLC - Registered owner: Daytona Aircraft Leasing Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 11, 2013, 78 hours before - Departed: DAB, Daytona Beach, FL - Destination: DAB, Daytona Beach, FL - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 26; injuries: none; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review April 23, 2013; seat: right; flight hours: 567 total, 88 in this make and model, 493 as pilot in command, 157 in the last 90 days, 67 in the last 30 days, 6 in the last 24 hours - Pilot; age 27; injuries: none; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; seat: left; flight hours: 111 total, 15 in this make and model, 56 as pilot in command, 39 in the last 90 days, 18 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 80° at 12 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 73 °F - Altimeter: 30.20 inHg - Observed at: OMN, 20 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 (OpenAirDocs). - [Incident 20130717015829I](https://openairdocs.org/incident/20130717015829I), Jul 17, 2013: Piper PA-34-200, Palm Coast, FL, Minor damage. During a VMC demonstration flight at approximately 5000 feet, 10 NM NE of Flagler County Airport, the aircrafts rudder began to oscillate. No emergency was… ## Docket (6 files) The files NTSB released with the investigation on December 22, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=87517. 6.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435151&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Phoenix East Event Report (item 2, .PDF, 367 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435152&FileExtension=.PDF&FileName=Phoenix%20East%20Event%20Report-Master.PDF - Memorandum of Record (item 3, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435153&FileExtension=.PDF&FileName=Memorandum%20of%20Record-Master.PDF - Annual Inspection (item 4, .PDF, 331 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435154&FileExtension=.PDF&FileName=Annual%20Inspection-Master.PDF - Materials Laboratory Factual Report (item 5, .PDF, 7 photos, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435155&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report-Master.PDF - Photo 1 - Tail of Airplane with Broken Rod (Courtesy of Phoenix East Aviation) (item 6, .PDF, 1 photo, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435156&FileExtension=.PDF&FileName=Photo%201%20-%20Tail%20of%20Airplane%20with%20Broken%20Rod%20(Courtesy%20of%20Phoenix%20East%20Aviation)-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.