# NTSB ERA16LA296: Mantell Allan T Kitfox 4 1200, N51TM, Canandaigua, NY, August 20, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: August 20, 2016, 10:00 local (14:00 UTC) - Place: Canandaigua, NY - Coordinates: 42.908889, -77.325279 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.9089&lon=-77.3253&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report October 17, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 93872 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16LA296 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93872/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93872 - Page: https://openairdocs.org/ntsb/ERA16LA296 ## Probable cause The failure of the right rudder pedal torque tube due to fatigue, which resulted in a loss of directional control during landing. Also causal to the accident was the airplane owner/builder's failure to install a rudder torque tube reinforcement or replacement in accordance with the kit manufacturer's recommendation. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Flight control system: rudder control system](https://openairdocs.org/ntsb-findings/01022720): Aircraft › Aircraft systems · Fatigue/wear/corrosion (probable cause); cases with it: [All aircraft, 93 cases](https://openairdocs.org/ntsb-findings/01022720/cases.md) - [Flight control system: rudder control system](https://openairdocs.org/ntsb-findings/01022720): Aircraft › Aircraft systems · Failure (probable cause); cases with it: [All aircraft, 93 cases](https://openairdocs.org/ntsb-findings/01022720/cases.md) - [Maintenance](https://openairdocs.org/ntsb-findings/02062000): Personnel issues › Task performance · Owner/builder (probable cause); cases with it: [All aircraft, 143 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Owner/builder (probable cause); cases with it: [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) (defining event); cases with it: [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) - [Landing: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The private pilot, who was also the owner/builder of the experimental, amateur-built, tailwheel-equipped airplane, was conducting a cross-country personal flight. He reported that, during landing, a rudder pedal torque tube separated, which resulted in a loss of directional control and the airplane departing the right side of the runway. Metallurgical examination revealed that the vertical torque tube for the right rudder pedal had fractured at a fillet welded intersection where it attached to a horizontal torque tube. The fracture surface exhibited a small thumbnail-like fatigue region followed by an overstress region. The pilot had assembled the airplane about 16 years before the accident, and it had accrued about 551 hours of operation. The actual kit model was manufactured 22 years before the accident, and 1 year later, the kit manufacturer published a service letter (SL) applicable to the accident airplane model, which advised owners that the company had recently noticed signs of fatigue in rudder pedal torque tubes. The SL instructed owners to inspect the areas for fatigue and offered a reinforcement kit. Further, 6 years later, the kit manufacturer redesigned the rudder pedal torque tubes for subsequent models to include a reinforcement similar to the reinforcement that had previously been offered in the reinforcement kit. The accident airplane was not equipped with the reinforcement kit recommended in the SL nor was it equipped with the newer rudder torque tube design. ## Factual narrative On August 20, 2016, about 1000 eastern daylight time, an experimental amateur-built Kitfox 4-1200, N51TM, was substantially damaged while landing at Canandaigua Airport (D38), Canandaigua, New York. The private pilot was not injured. The airplane was registered to and operated by the private pilot as a personal flight conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the flight that originated from Whitfords Airport (B16), Weedsport, New York, about 0920.The pilot reported that while landing on a turf airstrip adjacent to runway 31, a rudder pedal torque tube separated and the airplane departed the right side of the runway. The airplane subsequently impacted an uneven field and came to rest upright. Examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the wings and fuselage. The separated section of rudder pedal torque tube was retained and forwarded to the National Transportation Safety Board Materials Laboratory for further examination. Metallurgical examination revealed that the vertical torque tube for the right rudder pedal fractured at a fillet welded intersection where it attached to a horizontal torque tube. The fracture surface exhibited a small thumbnail like fatigue region followed by an overstress region. The single-seat, high-wing, tailwheel-equipped airplane, serial number C9406-0031, was assembled from a kit by the pilot in 2000 and issued an FAA experimental airworthiness certificate. Its most recent condition inspection was completed on August 8, 2016. At that time, the airframe had accumulated 547.4 total hours of operation. It had flown an additional 3.3 hours from the time of the last inspection, until the accident. The FAA inspector that examined the wreckage further stated that although assembly of the accident airplane was completed in 2000, the kit was actually a 1994 model. On August 22, 1995, the kit manufacturer released Service Letter No. 47 (SL-47), applicable to the accident airplane model, which advised owners that the company had recently noticed signs of fatigue in rudder pedal torque tubes. The SL instructed owners to inspect the areas for fatigue and offered a reinforcement kit (P/N 35015.000) for $59.95. Further, in 2000, the kit manufacturer redesigned the rudder pedal torque tubes for subsequent models, to include a reinforcement similar to what had previously been offered in the reinforcement kit. The inspector added that the accident airplane was not equipped with the newer rudder torque tube design, nor was it equipped with the reinforcement kit offered in SL-47. ## Aircraft - Registration: N51TM (not matched to a registry record) - Reported make and model: MANTELL ALLAN T KITFOX 4 1200 (IV) - Category: Airplane, amateur-built - Serial number: C9406-0031 - Year built: 2000 - Airframe hours: 551 - Engines: Jabiru 2200 80 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, August 8, 2016, 3 hours before - Departed: B16, Weedsport, NY - Destination: D38, Canandaigua, NY - Airport: D38, Canandaigua, runway 31, 950 × 25 ft, grass/turf - Equipment: Handheld GPS, Electronic primary flight display, Electronic multifunction display, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 75; injuries: none; private; airplane ratings: single-engine land, single-engine sea; medical: sport pilot; last flight review April 22, 2015; seat: left; restraint: 4-point; flight hours: 1,667 total, 600 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 63 °F - Altimeter: 29.90 inHg - Observed at: PEO, 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 20160820014629A](https://openairdocs.org/incident/20160820014629A), Aug 20, 2016: Mantell Allan T KITFOX 4-1200, Canandaigua, NY, Substantial damage. Upon landing the right rudder pedal broke and induced an uncontrolled landing/ground loop. Structure damage to the fuselage, wings and tail section. ## Docket (8 files) The files NTSB released with the investigation on August 21, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93872. 1.9 MB in all. - Materials Laboratory Factual Report (item 1, .PDF, 4 photos, 472 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455504&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 660 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455505&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Interview Summary (item 3, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455506&FileExtension=.PDF&FileName=Interview%20Summary-Master.PDF - Kit Manufacturer Service Letter (item 4, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455507&FileExtension=.PDF&FileName=Kit%20Manufacturer%20Service%20Letter-Master.PDF - Kit Manufacturer Rudder Pedal Redesign (item 5, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455508&FileExtension=.PDF&FileName=Kit%20Manufacturer%20Rudder%20Pedal%20Redesign-Master.PDF - Weather Report (item 6, .PDF, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455509&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - Evidence Control Form (item 7, .PDF, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455510&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Master.PDF - Photo Array (Courtesy of FAA) (item 8, .PDF, 2 photos, 279 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455511&FileExtension=.PDF&FileName=Photo%20Array%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.