ERA22LA358

NTSB accident investigation · Cessna 207 · Dillingham, AK · July 28, 2022

Accident · No injuriesClass 3 · LimitedFinal report
Date
July 27, 2022, 17:25 local (Jul 28, 2022, 01:25 UTC)
Place
Dillingham, AK
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N6908MCessna 207
Defining event
Enroute: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20220727007549A
Case key
105670

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 detect and correct improper rudder control system alignment, the resulting interference with the pulley’s rotation, and the accelerated corrosion and wear of the control cable, which ultimately led to its failure in flight.

Findings · 2

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.

Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelCessna 207A: 1 caseAll aircraft: 320 casesProbable cause
Flight control system: rudder control systemAircraft › Aircraft systems · Fatigue/wear/corrosionCessna 207A: 1 caseAll aircraft: 93 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 reported that, during approach to landing, he became aware that the left rudder pedal was not responsive. He declared an emergency and landed uneventfully. Examination revealed that the left rudder cable fractured due to corrosion and severe cable wear at the left pulley location. Nearly all wires on the cable were worn to a chisel-like point, leaving a small number of wires in the core strand to fracture in ductile overstress during final separation. The cable corrosion and wear were likely accelerated due to sliding contact with the left pulley. Issues with the rudder control system installation were evident on both pulleys. Rubbing damage on the face of the left pulley indicated that the pulley was contacting adjacent structure at the outer diameter. This contact likely interfered with pulley rotation, leading to the accelerated corrosion and wear of the control cable from sliding contact within the pulley groove. Although no rubbing damage was observed on the right pulley, the cable contact pattern was offset from the groove centerline, indicating an alignment problem in the rudder control system at the right pulley. Review of the maintenance logs revealed that the last inspection of the flight controls was completed about 8 months before the accident, and an entry about 3 months later noted a stuck pulley and corrosion of the left rudder cable. The maintenance response to the entry stated, “upon further inspection, determined cable not corroded. . . No defects.” Given the findings of the postaccident examination, it is likely that the accident would have been prevented had maintenance personnel taken more proactive action at that time.

Factual narrative

On July 27, 2022, about 1725 Alaska daylight time, a Cessna 207A, N6908M, was substantially damaged when it was involved in an accident near Dillingham, Alaska. The pilot and two passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 135 scheduled flight. The pilot reported that, during approach to landing he became aware that the left rudder pedal was not responsive. The pilot declared an emergency and landed uneventfully. Examination of the airplane by a Federal Aviation Administration inspector revealed that one of the rudder cables had fractured, and rust was visible at the fracture location. Because the failure of the rudder cable adversely affected the performance and flight characteristics of the airplane and required replacement of the cable, the damage to the airplane was substantial. Follow-up examination revealed that the rudder cable was fractured about 94 inches from the turnbuckle terminal end and 152 inches from the center of the attachment holes in the clevis at the other end. The bearings at the centers of the pulleys moved freely in both submitted pulleys; however, examination revealed abrasion of the outer rim of the left pulley and orange deposits consistent with rust in the groove for the left pulley in addition to rubbing around much of the circumference of the groove contact surface. Although no rubbing damage was observed on the right pulley, the cable contact pattern was offset from the groove centerline. The fractured ends of the cable were mostly worn to a tapered end with no discernable fracture features, consistent with ductile overstress fracture. Review of the maintenance logs revealed that the last inspection of the flight controls was completed on November 23, 2021, about 8 months before the accident, at an airplane total time of 40,516.8 hours. An entry on January 5, 2022, and airplane total time 40,536.6 hours, notated that “the left hand rudder stuck pulley at the aft baggage bulkhead” as well as “corrosion of the L/H rudder cable at aft baggage bulkhead.” The mechanic’s response to the entry stated, “upon further inspection, determined cable not corroded. . . No defects.” The airplane had accrued 40,885 total hours at the time of the accident.

Aircraft

Registration
N6908M
Reported as
Cessna 207 (A)
Category
Airplane
Serial number
20700672
Built
1980
Airframe hours
40,885
Engine
Cont Motor IO-520-F, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Grant Aviation Inc
Registered owner
Grant Aviation Inc
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · July 19, 2022
Departed
ANW · New Stuyahok, AK
Destination
Same as departure
Flight plan
Company VFR
Airport
DLG · Dilingham, runway 01, 6,400 × 150 ft, asphalt
Equipment
Stall warning system, Satellite tracking device

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
30
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
March 7, 2022
Seat
Left
Flight hours
1,240 total · 316 in this make and model · 1,100 as pilot in command · 150 in the last 90 days · 35 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
10° at 10 knots, gusting 14
Visibility
10 statute miles
Lowest ceiling
None
Temperature
68 °F, dew point 43 °F
Altimeter
30.19 inHg
Icing
Unknown
Observed at
ADL
METAR
PADL 280056Z 01010G14KT 10SM CLR 20/06 A3019 RMK AO2 SLP224 T02000056

Docket · 5

The files NTSB released with the investigation on January 4, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.0 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.