FTW95LA138

NTSB accident investigation · Cessna 340 · Santa Fe, NM · March 14, 1995

Accident · No injuriesLimited investigationFinal report
Date
March 14, 1995, 14:50 local (21:50 UTC)
Place
Santa Fe, NM
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N5432MCessna 340
Weather
Visual (VMC) · Day
Status
Completed · report November 30, 1995
Report
Approved by Office Director
FAA report
19950314004749A
Case key
19369

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

Worn landing gear assembly due to inadequate maintenance by maintenance personnel and delayed maintenance by operators.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Gear collapsedLanding - roll
Landing gear,main gear - collapsed
Landing gear,normal retraction/extension assembly - wornCause
Maintenance - inadequateOther maintenance personnelCause
Maintenance,replacement - delayedCompany/operator managementCause

Analysis

The right main gear collapsed for the second time within 21 days after 7.7 hours of flight hours since the repair. Since the last annual inspection the landing gear had been inspected various times and numerous gear system discrepancies were noted to mechanics and owners/operators. Post accident examination of the system by the manufacturer's technical representative revealed 'extreme' wear in the landing gear system. A review of maintenance records did not reveal replacement of any bushings in the right main landing gear assembly during numerous landing gear checks. A Cessna service letter for main landing gear side brace had not been accomplished.

Factual narrative

On March 14, 1995, at 1450 mountain standard time, a Cessna 340, N5432M, sustained substantial damage when the right main gear collapsed during landing near Santa Fe, New Mexico. The private pilot and the sole passenger were not injured. Visual meteorological conditions prevailed for the local personal flight being operated under Title 14 CFR Part 91.

The flight was cleared by the tower controller to land on runway 02 and during the landing roll, the right main gear collapsed. The right wing struck the runway and the airplane came to rest with damage to the right aileron, flap, propeller, landing light, and wing tip fuel tank.

The landing gear was checked and lubricated at an annual inspection on March 26, 1994, at Robertson Aircraft, Inc., at Albuquerque, New Mexico. Robertson wrote an airplane discrepancy log entry for April 29, 1994, stating "check landing gear" and listing under the corrective action block that "gear needs all new bushings and tension set." The log further stated that the "pilot said not to do anything." On August 10, 1994, a pre-purchase inspection report (copy enclosed) for the current owner listed numerous landing gear system discrepancies including right main gear side brace "play at the upper attachment point and at the center pivot point." The inspection report also stated "gear tensions low, gear system needs rigging."

The airplane was purchased by the current owner on October 11, 1994. In November 1994, maintenance was accomplished on the landing gear transmission, manual gear extension system, the left main gear assembly (including replacement of bushings in drag link); however, maintenance records did not indicate work on the right main gear assembly. In December 1994, maintenance included gear box repair, installation of new bushings in the left gear and adjusting the up and down locks and overcenter pressures.

After 4.6 hours of flight time since the last recorded landing gear maintenance, the right main gear collapsed, on February 2, 1995. The enclosed inspection sheet, work order, and parts listing did not reveal replacement of main gear bushings. The maintenance logbook states "performed gear rig and operational test." On the enclosed statement, dated September 19, 1995, Beegles Aircraft Service, Inc., stated that after the first gear collapse, a "replacement of parts and inspection of the other parts was completed and gear rigging procedure completed." Beegles Aircraft further stated that the "gear system rigged out according to the manual." On March 1, 1995, Beegles Aircraft Service of Greeley, Colorado, stated in the maintenance log that the "aircraft was repaired and inspected" and "is approved for return to service."

On March 14, 1995, 7.7 hours of flight time after the first gear collapse, the right main gear collapsed for a second time. In April 1995, the airplane was examined at Beegles Aircraft Service, Inc., by a NTSB investigator and the manufacturer's technical representative. The technical representative found "the whole landing gear system was extremely worn" and "every place there was a bearing, bushing, or bolt was excessively worn." According to the technical representative, "the extreme wear of the complete gear actuating system caused the gear rigging parameters to change with each actuation and at the time of collapse, had changed enough to prevent the downlock from locking properly." On the enclosed statement, Beegles Aircraft Service, Inc., reported that after the second gear collapse they became aware of the maintenance on gear door hinges and the transmission.

On May 16, 1995, the manufacturer's engineer reviewed the history of the airplane and stated that it was his "suspicion that the rigging of the aircraft is changing and that the right gear is loosing its over center adjustment as a result of the existing crack in the gear box area as well as the worn out bushings." On the enclosed statement, Beegles Aircraft Service, Inc., reported that "the wing rib in the main gear wheel well of this airplane have cracks" as outlined in the Cessna Service Letter ME76-2. Airplane maintenance records did not indicated that the service letter had not been accomplished by previous owners or maintenance personnel.

The right upper struts and bellcranks from the two occurrences of the right main gear collapse were examined by the NTSB Metallurgists. Each strut and bellcrank contained "similar separations" and disclosed "no evidence of preexisting fractures." All fractures were "typical of overstress."

The airplane was released to the owner.

Aircraft

Registration
N5432M
Reported as
Cessna 340
Category
Airplane
Serial number
340-0033
Airframe hours
4,473
Engine
Continental TSIO-520, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Norman K. Moses
Registered owner
John Gundzik
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 26, 1994 · 112 hours before
Departed
SAF
Airport
SAF · Santa Fe Municipal, runway 2, 8,324 × 150 ft, asphalt

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
41
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
1,750 total · 30 in this make and model · 1,700 as pilot in command · 120 in the last 90 days · 40 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
50 statute miles
Lowest ceiling
None
Temperature
70 °F
Altimeter
30.00 inHg

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.