ERA18LA178

NTSB accident investigation · Piper PA 34-200 · Umatilla, FL · June 14, 2018

Accident · Minor injuriesLimited investigationFinal report
Date
June 14, 2018, 09:50 local (13:50 UTC)
Place
Umatilla, FL
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N56213Piper PA 34-200
Defining event
Landing-landing roll: Loss of control on ground
Weather
Visual (VMC) · Day
Status
Completed · report November 6, 2019
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20180614007909A
Case key
97564

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

Maintenance personnel ‘s failure to complete and verify the proper installation of the main landing gear (MLG) torque links’ attachment hardware, which resulted in the right MLG torque link disconnecting and the pilot’s subsequent inability to maintain directional control during the landing roll.

Findings · 6

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.

Landing gear system: main gear strut/axle/truckAircraft › Aircraft systems · Incorrect service/maintenancePiper PA-34-200: 1 caseAll aircraft: 86 casesProbable cause
Landing gear system: main gear strut/axle/truckAircraft › Aircraft systems · Inadequate inspectionPiper PA-34-200: 1 caseAll aircraft: 86 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelPiper PA-34-200: 2 casesAll aircraft: 371 casesProbable cause
Inspection: post maintenance inspectionPersonnel issues › Task performance · Maintenance personnelPiper PA-34-200: 1 caseAll aircraft: 57 casesProbable cause
Action: forgotten action/omissionPersonnel issues › Action/decision · Maintenance personnelPiper PA-34-200: 4 casesAll aircraft: 440 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Attain/maintain not possiblePiper PA-34-200: 3 casesAll aircraft: 3,958 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

The pilot receiving instruction and the flight instructor were conducting an instructional flight. During the approach to the destination airport, the pilot receiving instruction lowered the landing gear, and the instructor confirmed that the down-and-locked indications were all green. After touchdown and during the landing roll, the airplane suddenly entered an uncommanded and violent right swerve, which the pilot receiving instruction could not correct with full left brake, rudder, and aileron inputs. Subsequently, the airplane departed the runway and impacted a drainage ditch. Postaccident examination of the airplane revealed that the upper and lower torque links of the right main landing gear (MLG) were undamaged and not attached; the attachment hardware was not in place nor recovered. Examination of the left MLG revealed that the upper and lower torque links remained connected, but a cotter pin was not found installed through the castellated nut and drilled bolt. A review of the airplane's maintenance logbooks revealed that, about 1 month before the accident, the attachment hardware for the left and right torque links was replaced, which included the installation of cotter pins. The mechanic who signed off the inspection stated that, during subsequent maintenance, both torque links' cotter pins were removed and that, although the attachment hardware at both torque links was subsequently tightened, neither of the torque link's cotter pins were installed before the airplane was approved for return to service. Therefore, it is likely that the right MLG torque link attachment hardware loosened over time due to the lack of a cotter pin and eventually separated from the airplane, which resulted in the torque link becoming disconnected and led to the pilot's subsequent inability to maintain directional control during landing.

Factual narrative

On June 14, 2018, about 0950 eastern daylight time, a Piper PA-34-200, N56213, was substantially damaged during a runway excursion while landing at Umatilla Municipal Airport (X23), Umatilla, Florida. The flight instructor was not injured while the pilot undergoing instruction (PUI) sustained a minor injury. The airplane was owned by Elite Florida AC LLC, and operated by Spaceport Aviation under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the instructional flight, which originated from Space Coast Regional Airport (TIX), Titusville, Florida, about 0845, and was destined for X23.The PUI and/or the flight instructor stated that the flight proceeded to X23 where the downwind leg of the airport traffic pattern was extended, and the required before landing checks were performed. The PUI stated that he extended the landing gear, and the flight instructor confirmed there were 3 green lights displayed indicating all landing gears were down and locked. After touchdown on runway 01 at 80 miles-per-hour, the airplane suddenly began an uncommanded and violent swerve to the right, which the PUI could not correct with full left brake, rudder, and aileron inputs. The airplane departed the runway and impacted a drainage ditch. The PUI stated that while assessing the airplane with the mechanic from X23, they noticed the securing hardware for the upper and lower torque links of the right main landing gear was not in place. According to a Federal Aviation Administration inspector who responded to the accident site, a search was made for the missing right main landing gear hardware and it was not located. He inspected both disconnected torque links and did not see damage to either, nor did he see scoring damage to the inner diameter of the right main landing gear torque link brass sleeve that the attachment bolt passes through to secure the torque links together. The brass sleeve was measured and found to be round and not elongated. He also inspected the left main landing gear and found its torque link secured with the bolt, washer and castellated nut, but the cotter pin was missing. A review of the airframe maintenance records revealed during the airplane's last annual inspection which was signed off as being completed on May 16, 2018, new hardware was installed in both main landing gear torque links.The mechanic who signed off the inspection stated that as part of the new hardware at the torque links, cotter pins were installed, but because of clearance issues during subsequent gear retraction testing, the hardware at both torque links was loosened to adjust each brake hose, then the hardware was tightened after adjustment, but the cotter pins at both gear torque links were not installed. A review of the airplane's Pilot's Operating Handbook revealed that as part of the preflight inspection, it specified a visual inspection of the right main landing gear for leaks,the tires for inflation and wear, and the landing gear strut piston for proper extension. There was no direct mention to inspect the torque links for security.

Aircraft

Registration
N56213
Reported as
Piper PA 34-200 (200)
Category
Airplane
Serial number
347350304
Built
1973
Airframe hours
4,031.44
Engines
Lycoming LIO-360-C1E6, 200 horsepower, reciprocatingLycoming IO-360-C1E6, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Spaceport Aviation
Registered owner
Elite Florida AC LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 16, 2018
Departed
TIX · Titusville, FL
Destination
X23 · Umatilla, FL
Airport
X23 · Umatilla Municipal Airport, runway 01, 2,500 × 60 ft, asphalt
Equipment
Electronic flight bag or handheld device, Stall warning system

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
54
Injuries
None
Certificates
Airline transport, Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
September 1, 2016
Seat
Right
Restraint
3-point
Flight hours
6,922 total · 84 in this make and model · 5,339 as pilot in command · 154 in the last 90 days · 47 in the last 30 days · 5.3 in the last 24 hours
Role
Student pilot
Age
56
Injuries
Minor
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 1, With waivers/limitations
Seat
Left
Flight hours
9,307 total · 20 in this make and model · 8,015 as pilot in command · 20 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 75 °F
Altimeter
30.12 inHg
Turbulence
Unknown
Observed at
KLEE, 10 nm away

Docket · 8

The files NTSB released with the investigation on April 3, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.8 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.