# NTSB ERA13LA191: Cessna 414, N37480, Hammonton, NJ, April 5, 2013 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: April 5, 2013, 11:50 local (15:50 UTC) - Place: Hammonton, NJ - Coordinates: 39.667499, -74.757774 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.6675&lon=-74.7578&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report February 10, 2014 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Cessna Aircraft Company - NTSB case key (mKey): 86595 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA13LA191 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/86595/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=86595 - Page: https://openairdocs.org/ntsb/ERA13LA191 ## Probable cause A loss of control during landing due to the failure of the nose landing gear's left trunnion lug. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Landing gear system: nose/tail gear attach section](https://openairdocs.org/ntsb-findings/01023221): Aircraft › Aircraft systems · Failure (probable cause); cases with it: [Cessna 414, 1 case](https://openairdocs.org/ntsb-findings/01023221/cases.md?model=2075908), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/01023221/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Cessna 414, 3 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2075908), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 414, 8 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2075908), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that, during a repositioning flight, he lowered the landing gear during the approach and confirmed that it was extended by observing the landing gear position indicator lights. Immediately after touchdown, the airplane veered left. The pilot applied full right rudder, but the airplane continued veering left and departed the left side of the runway. The airplane struck several trees and was subsequently engulfed in a postcrash fire. A postaccident examination revealed that the nose landing gear had separated from its mount at the left trunnion. Fractographic examination revealed a pre-existing crack at the surface of the left trunnion lug. Subsequent investigation revealed that the fractured part was a used part recently taken from another airplane that had over 20,000 service hours. The crack at the surface of the trunnion lug could not have been seen during a visual inspection of the trunnion assembly before its installation because such cracks can only be identified by eddy current inspections. Multiengine Service Bulletin MEB88-5 requires the trunnion assembly to be subjected to eddy current inspection and, if cracks are identified during this inspection, the trunnion assembly must be replaced; however, the inspection requirements are not applicable to Part 91 operators. ## Factual narrative On April 5, 2013, about 1150 eastern daylight time, a Cessna 414, N37480, registered to and operated by a private individual, was substantially damaged when it veered off the runway while landing at Hammonton Municipal Airport (N81), Hammonton, New Jersey. The private pilot was not injured and the commercial pilot-rated passenger received minor injuries. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the flight. The flight originated from Montgomery County Airpark (GAI), Gaithersburg, Maryland about 1105 and was destined for N81. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The airplane was being repositioned to N81 in order for the owner's insurance adjuster and a local mechanic to physically inspect previous claim work for damage done during ground handling following Hurricane Sandy. The pilot reported lowering the landing gear during the approach to runway 03, and confirmed that they were extended by observing the landing gear position indicator lights. Immediately after touchdown, the airplane veered to the left. The pilot applied full right rudder, but the airplane continued to veer to the left. After departing the left side of the runway, the airplane struck several trees and was subsequently engulfed in a post-crash fire. According to FAA records, the pilot held a private certificate, with ratings for airplane single- and multiengine land. His most recent FAA third class medical certificate was issued on January 2, 2013. As of April 5, 2013, the pilot reported a total of 587 total hours of flight experience, of which 120 hours were in the same make and model as the accident airplane. The seven-seat, twin-engine, low-wing, retractable tricycle-gear airplane was manufactured in 1977 and was equipped with two Continental Motors TSIO-520, 520-hp engines. Review of the airplane's maintenance logbooks revealed that its most recent annual inspection was completed on October 26, 2012. At the time of inspection, the airplane had accumulated 9,335 total hours in service. The number one and two engines accumulated approximately 735 and 157 total hours of operation since overhaul, respectively. The airplane had flown about three hours since the most recent annual inspection. The 1154 recorded weather observation at Atlantic City International Airport (ACY), Atlantic City, New Jersey, located about 15 miles southeast of the accident site, included wind from 330 degrees at 13 knots, 10 miles visibility, few clouds at 1,600 feet, temperature 11 degrees C, dew point 4 degrees C, and a barometric altimeter setting of 29.83 inches of mercury. N81 was a non-tower-controlled airport equipped with one asphalt runway, oriented in a 03/21 configuration. The runway was 3,601 feet in length and 75 feet wide. The field elevation for the airport was 65 feet mean sea level. Examination of the accident site and surrounding area by a Federal AviationAdministration (FAA) inspector revealed the left wing impacted several 4 to 6 inch-diameter trees prior to separating from the aircraft. The airplane then spun to the left, with fuel from the severed wing splashing on the nose section of the airplane and onto the hot left engine. The fuel ignited and caused substantial damage to the left engine and forward left section of the fuselage. Post-accident examination also revealed that the nose landing gear (NLG) had separated from its mount at the nose trunnion. Further investigation revealed that the left NLG trunnion lug had sheared from the trunnion assembly. The fractured lug was sent to the manufacturer for fractographic examination. The examination revealed a pre-existing crack at the surface of the NLG trunnion lug. The crack was approximately 0.015 inch deep at the time of final fracture. Subsequent investigation revealed that the fractured component was taken from a Cessna 310 airplane, and had accumulated approximately 20,000 service hours. According to maintenance records, on March 12, 2013, the nose gear attached tunnel and forward bulkhead were repaired as part of the filed insurance claim, and the nose gear trunnion assembly was replaced at this time. Cessna Multi-engine Service Bulletin MEB88-5 (Revision 2), Nose Gear Trunnion/Replacement, stated the preferred inspection method for the side lug area was a surface eddy current inspection. An alternate fluorescent penetrant inspection may be used for those facilities without eddy current inspection capabilities. However, MEB88-5 was not a federally mandated requirement for all owner/operators to accomplish. Subsequently, the subject trunnion assembly installed on the accident airplane had received only a visual examination prior to installation. ## Aircraft - Registration: [N37480](https://openairdocs.org/deregistered/N37480-2018-05-30), registration cancelled 2018-05-30, S/N 414-0958, built 1977 (OpenAirDocs) - Reported make and model: CESSNA 414 (UNDESIGNAT) - Registry model: [Cessna 414](https://openairdocs.org/model/cessna-414) (registry code 2075908) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 414-0958 - Year built: 1977 - Airframe hours: 9376 - Engines: CONT MOTOR TSIO-520 SER 300 horsepower reciprocating; CONT MOTOR TSIO-520 SER 300 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Terry Luis A - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 26, 2012, 3 hours before - Departed: GAI, Gaithersburg, MD - Destination: N81, Hammonton, NJ - Flight plan: VFR/IFR - Airport: N81, Hammonton Municipal Arpt, runway 03, 3,601 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; injuries: none; private; airplane ratings: multi-engine land, single-engine land; medical: class 3, with waivers/limitations; last flight review January 9, 2012; seat: left; flight hours: 587 total, 120 in this make and model, 480 as pilot in command, 22 in the last 90 days, 14 in the last 30 days - Co-pilot; age 29; injuries: minor; commercial, flight instructor, private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review August 31, 2012; seat: right; flight hours: 1,400 total, 20 in this make and model, 1,320 as pilot in command, 260 in the last 90 days, 84 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 13 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 52 °F, dew point 39 °F - Altimeter: 29.82 inHg - Observed at: ACY, 15 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). - [Accident 20130405005849A](https://openairdocs.org/incident/20130405005849A), Apr 5, 2013: Cessna 414, Hammonton, NJ, Substantial damage. On April 5, 2013, at approximatly 11:51 eastern standard time, a Cessna 414 multi-engine airplane, N37480, piloted by, [privacy data omitted], crashed into… ## Docket (12 files) The files NTSB released with the investigation on December 4, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=86595. 27.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 543 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391961&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Passenger's Statement (item 2, .PDF, 199 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399450&FileExtension=.PDF&FileName=Passenger%27s%20Statement-Redacted.PDF - Airframe Maintenance Records (item 3, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40397190&FileExtension=.PDF&FileName=Airframe%20Maintenance%20Records-Redacted.PDF - Weather Reports and Records (item 4, .PDF, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390329&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Excerpt from Multi-engine Service Bulletin MEB88-5 Revision 2, Nose Gear Trunnion Inpsection/Replacement (item 5, .PDF, 549 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398924&FileExtension=.PDF&FileName=Excerpt%20from%20Multi-engine%20Service%20Bulletin%20MEB88-5%20Revision%202,%20Nose%20Gear%20Trunnion%20Inpsection%2FReplacement-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 6, .PDF, 259 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392114&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - FAA Safety Recommendation-Nose Landing Gear Trunnion assemblu (item 7, .PDF, 761 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399452&FileExtension=.PDF&FileName=FAA%20Safety%20Recommendation-Nose%20Landing%20Gear%20Trunnion%20assemblu-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 8, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399589&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photograph #1: Aft view of wreckage (Courtesy of FAA) (item 9, .PDF, 6.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391968&FileExtension=.PDF&FileName=Photograph%20%231%3A%20Aft%20view%20of%20wreckage%20(Courtesy%20of%20FAA)-Master.PDF - Photograph #2: Port view of wreckage (Courtesy of FAA) (item 10, .PDF, 8.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391970&FileExtension=.PDF&FileName=Photograph%20%232%3A%20Port%20view%20of%20wreckage%20(Courtesy%20of%20FAA)-Master.PDF - Photograph #3: Port view of wreckage (Courtesy of FAA) (item 11, .PDF, 5.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391971&FileExtension=.PDF&FileName=Photograph%20%233%3A%20Port%20view%20of%20wreckage%20(Courtesy%20of%20FAA)-Master.PDF - Photograph #4: Nose Landing Gear Trunnion (Courtesy of FAA) (item 12, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399451&FileExtension=.PDF&FileName=Photograph%20%234%3A%20Nose%20Landing%20Gear%20Trunnion%20(Courtesy%20of%20FAA)-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.