# NTSB ERA18LA220: Czech Sport Piper Sport, N425AZ, Stuart, FL, August 15, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: August 15, 2018, 12:00 local (16:00 UTC) - Place: Stuart, FL - Coordinates: 27.181667, -80.221389 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=27.1817&lon=-80.2214&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Landing gear collapse](https://openairdocs.org/ntsb-events/094) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report September 27, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 98090 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18LA220 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98090/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98090 - Page: https://openairdocs.org/ntsb/ERA18LA220 ## Probable cause Inadequate maintenance inspection of the airplane's nose landing gear, which resulted in a nose landing gear collapse during landing due to cracking and corrosion. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Czech Sport PIPER SPORT, 2 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=0600073), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md) - [Landing gear system: nose/tail gear strut/axle](https://openairdocs.org/ntsb-findings/01023222): Aircraft › Aircraft systems · Inadequate inspection (probable cause); cases with it: [Czech Sport PIPER SPORT, 1 case](https://openairdocs.org/ntsb-findings/01023222/cases.md?model=0600073), [All aircraft, 36 cases](https://openairdocs.org/ntsb-findings/01023222/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: Landing gear collapse](https://openairdocs.org/ntsb-events/094) (defining event); cases with it: [Czech Sport PIPER SPORT, 2 cases](https://openairdocs.org/ntsb-events/094/sequence.md?model=0600073), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) ## Analysis The sport pilot was conducting a personal flight in the special light sport airplane. During landing, the airplane touched down normally on the main landing gear. After 50 ft of ground roll, the nose landing gear touched down and collapsed; one propeller blade subsequently separated, and the airplane came to rest upright on the runway. Examination of the airplane revealed that the nose landing gear had separated at a location that the airplane maintenance manual (AMM) and a service bulletin (SB) indicate should be inspected for cracks. The separated fracture surfaces exhibited cracking and corrosion. Review of the SB revealed that due to the development of cracks, an inspection for cracks per the AMM should occur every 25 flight hours or 50 cycles, whatever occurs first. The AMM stated to use a flashlight and 10x magnifier to visually inspect the nose landing gear leg lower section and verify that there is no evidence of cracking in paint on or around the place of the weld between the tube and the bracket. The most recent documented nose landing gear inspection was about 2 years 5 months before the accident. Thus, it is likely that the nose landing gear was not adequately inspected and cracks and corrosion were therefore undetected, which led to the nose landing gear collapse during landing. ## Factual narrative On August 15, 2018, about 1200 eastern daylight time, a special light sport aircraft (S-LSA) Czech Sport Aircraft AS Piper Sport, N425AZ, operated by the sport pilot, was substantially damaged during landing at Witham Field (SUA), Stuart, Florida. The sport pilot and passenger were not injured. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the local flight that departed SUA about 1100. The sport pilot reported that during landing on runway 16, the airplane touched down normally on the main landing gear. After 50 ft of ground roll, the nose landing gear touched down and collapsed. One propeller blade subsequently separated and the airplane came to rest upright on the runway. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the nose landing gear had penetrated the engine firewall. The inspector added that the nose landing gear had separated at a location where the airplane maintenance manual (AMM) and a service bulletin direct to inspect for cracks. The inspector further stated that the separated fracture surfaces exhibited cracking and corrosion. Review of SB-CR-016, published October 9, 2013, revealed: "…REASON: Some SportCruiser / PiperSport / PS-28 Cruiser aircraft have developed cracks in the bottom side of the lower section of the nose landing gear (NLG). The cracks develop on the NLG assembly along the weld of the tube and the bracket. Furthermore, on several aircraft bending of the pivot connecting the fork with leg was discovered and cracks from holes of bolts on the fork. To address this potentially unsafe condition, a repetitive inspection is required of the bottom side of the lower section, in the area of the weld of the tube, the bracket and the pivot and the fork in the place of the bolts mounting the fork to the landing gear. COMPLIANCE: A. Before next flight after issue of this bulletin. B. Periodically at each 25 FH or 50 cycles whatever occurs first check as described in documents [1] for PS-28 Cruiser and [2] for SportCruiser (see REFERENCES). C. During pre-flight check (see POH , Section 4, 4.1 Pre-flight check, Inspection Check List, Point 4 - Nose gear) visually inspect pivot (see the picture on the Page 3 of 4 of this Service Bulletin) and verify that there is no evidence of cracks or bending…" Review of the AMM, 8.4.3, revealed: "…(d) Using flashlight and 10x magnifier, visually inspect nose landing gear leg lower section and verify there is no evidence of cracking in paint on or around place of the weld of the tube and the bracket…" The two-seat, low-wing, fixed tricycle-gear airplane, was manufactured in 2010. It was powered by a Rotax 912 ULS, 100-horsepower engine, equipped with a ground-adjustable, two-blade Sensenich propeller. Review of maintenance records revealed that the airplane's most recent annual inspection was completed on March 26,2018. At that time, the airframe and engine had accrued 487.8 hours since new. The airplane flew an additional 24.8 hours from the time of the most recent inspection, until the accident. The most recent nose gear inspection documented in the maintenance records was dated March 14, 2016. ## Aircraft - Registration: [N425AZ](https://openairdocs.org/aircraft/N425AZ), registered now, S/N P1001082, built 2010 (OpenAirDocs) - Reported make and model: CZECH SPORT AIRCRAFT AS PIPER SPORT - Registry model: [Czech Sport PIPER SPORT](https://openairdocs.org/model/czech-sport-piper-sport) (registry code 0600073) (OpenAirDocs) - Registry engine: [Rotax 912ULS series](https://openairdocs.org/engine/rotax-912uls-series) (registry code 55572, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: P1001082 - Year built: 2010 - Airframe hours: 488 - Engines: Rotax 912 ULS 100 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 26, 2018, 25 hours before - Departed: SUA, Stuart, FL - Destination: SUA, Stuart, FL - Airport: SUA, Witham Field, runway 16, 4,998 × 100 ft, asphalt - Equipment: Electronic multifunction display, Auto-pilot, Airframe parachute, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: none; sport pilot; airplane ratings: single-engine land; medical: sport pilot; last flight review November 18, 2017; seat: left; restraint: 4-point; flight hours: 428 total, 144 in this make and model, 334 as pilot in command, 12 in the last 90 days, 5 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 120° at 10 knots - Visibility: 7 statute miles - Lowest ceiling: none - Temperature: 90 °F, dew point 75 °F - Altimeter: 30.12 inHg - Observed at: SUA ## 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 20180815016819A](https://openairdocs.org/incident/20180815016819A), Aug 15, 2018: Czech Sport Aircraft As PIPER SPORT, Stuart, FL, Substantial damage. Nose gear collapse on rwy 16 at Witham Field (sua). Normal landing, main gear, no hard landing. Upon nose whell toch down, rolled down runway approx 50FT when… ## Docket (7 files) The files NTSB released with the investigation on December 3, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98090. 4.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468769&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Inspector Statement (item 2, .PDF, 175 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468770&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF - Excerpt from Maintenance Records (item 3, .PDF, 192 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468771&FileExtension=.PDF&FileName=Excerpt%20from%20Maintenance%20Records-Master.PDF - Excerpt from Airplane Maintenance Manual (item 4, .PDF, 263 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468772&FileExtension=.PDF&FileName=Excerpt%20from%20Airplane%20Maintenance%20Manual-Master.PDF - Service Bulletin (item 5, .PDF, 153 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468773&FileExtension=.PDF&FileName=Service%20Bulletin-Master.PDF - Weather Report (item 6, .PDF, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468774&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - Photo Array (item 7, .PDF, 8 photos, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468775&FileExtension=.PDF&FileName=Photo%20Array-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.