# NTSB ERA18LA178: Piper PA 34-200, N56213, Umatilla, FL, June 14, 2018 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: June 14, 2018, 09:50 local (13:50 UTC) - Place: Umatilla, FL - Coordinates: 28.924165, -81.65139 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.9242&lon=-81.6514&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 November 6, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 97564 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18LA178 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97564/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97564 - Page: https://openairdocs.org/ntsb/ERA18LA178 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Landing gear system: main gear strut/axle/truck](https://openairdocs.org/ntsb-findings/01023213): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-34-200, 1 case](https://openairdocs.org/ntsb-findings/01023213/cases.md?model=7103405), [All aircraft, 86 cases](https://openairdocs.org/ntsb-findings/01023213/cases.md) - [Landing gear system: main gear strut/axle/truck](https://openairdocs.org/ntsb-findings/01023213): Aircraft › Aircraft systems · Inadequate inspection (probable cause); cases with it: [Piper PA-34-200, 1 case](https://openairdocs.org/ntsb-findings/01023213/cases.md?model=7103405), [All aircraft, 86 cases](https://openairdocs.org/ntsb-findings/01023213/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) - [Inspection: post maintenance inspection](https://openairdocs.org/ntsb-findings/02061515): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-34-200, 1 case](https://openairdocs.org/ntsb-findings/02061515/cases.md?model=7103405), [All aircraft, 57 cases](https://openairdocs.org/ntsb-findings/02061515/cases.md) - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Maintenance personnel (probable cause); cases with it: [Piper PA-34-200, 4 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=7103405), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Piper PA-34-200, 3 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=7103405), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/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) - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Piper PA-34-200, 4 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7103405), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Piper PA-34-200, 3 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=7103405), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Piper PA-34-200, 3 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7103405), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-34-200, 10 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103405), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N56213), registered now, S/N 347350304, built 1973 (OpenAirDocs) - Reported make and model: PIPER PA 34-200 (200) - Registry model: [Piper PA-34-200](https://openairdocs.org/model/piper-pa-34-200) (registry code 7103405) (OpenAirDocs) - Registry engine: [Lycoming IO-360-C1E6](https://openairdocs.org/engine/lycoming-io-360-c1e6) (registry code 41835, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 347350304 - Year built: 1973 - Airframe hours: 4031.44 - Engines: LYCOMING LIO-360-C1E6 200 horsepower reciprocating; LYCOMING 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 54; injuries: none; 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 - Student pilot; age 56; injuries: minor; 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 ## 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 20180614007909A](https://openairdocs.org/incident/20180614007909A), Jun 14, 2018: Piper PA-34-200, Umatilla, FL, Substantial damage. N56213 a Piper PA-34-200 (serial number 347350304) was being operated by spaceport aviation and was conducting pilot training under CFR part 61. On 06/14/2018… ## Docket (8 files) The files NTSB released with the investigation on April 3, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97564. 8.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - Submitted by Pilot Undergoing Instruction (item 1, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471621&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20Submitted%20by%20Pilot%20Undergoing%20Instruction-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - Submitted by Flight Instructor (item 2, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471622&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20Submitted%20by%20Flight%20Instructor-Master.PDF - FAA Inspector Statement (item 3, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471624&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF - Excerpt from Airframe Maintenance Records (item 4, .PDF, 458 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471623&FileExtension=.PDF&FileName=Excerpt%20from%20Airframe%20Maintenance%20Records-Master.PDF - Excerpts from Airplane Parts Catalog (item 5, .PDF, 347 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471625&FileExtension=.PDF&FileName=Excerpts%20from%20Airplane%20Parts%20Catalog-Master.PDF - Statement from Mechanic (item 6, .PDF, 281 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471626&FileExtension=.PDF&FileName=Statement%20from%20Mechanic-Master.PDF - Investigative Photographs (item 7, .PDF, 757 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471627&FileExtension=.PDF&FileName=Investigative%20Photographs-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 8, .PDF, 519 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471628&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.