# NTSB LAX03LA228: Piper PA-28-181, N288PA, Phoenix, AZ, July 7, 2003 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: July 7, 2003, 12:56 local (19:56 UTC) - Place: Phoenix, AZ - Coordinates: 33.688056, -112.082496 - Nearby events: https://openairdocs.org/map.md?lat=33.6881&lon=-112.0825&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report September 29, 2004 - Report: Approved by Office Director - Parties: The New Piper Aircraft Company, Federal Aviation Administration - NTSB case key (mKey): 57426 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX03LA228 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/57426/pdf - Page: https://openairdocs.org/ntsb/LAX03LA228 ## Probable cause The disengagement of the left control wheel from the control column, which was due to the attaching screw backing out of the nut plate. Also causal was the manufacturer's inadequate design of the installation and the improper length of the screw. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, maneuvering - flt control syst,yoke/control stick - loose part/bolt/nut/clamp/etc (cause) - acft/equip,inadequate design, manufacturer (cause) - flt control syst,yoke/control stick - disengaged (cause) - Loss of control - in flight, maneuvering - aircraft control - unavailable, pilot in command - Forced landing, emergency descent/landing - On ground/water collision with object, landing - object - tree(s) ## Analysis The airplane lost aileron control while practicing commercial pilot maneuvers, resulting in a collision with a tree during the subsequent emergency landing. The pilot stated that he moved the control wheel to the right, but the airplane did not respond. He looked at the wing as he continued moving the control wheel and realized that the ailerons were not operating. He landed the airplane on a dirt road using rudder and throttle to control movement. During the landing, the right wing impacted a tree. The design of the control wheel to control column interface utilizes a nut plate installed inside the column. A screw and collar are then inserted through the bottom of the control wheel and into the nut plate inside the column to secure it to the column. Various Federal Aviation Administration (FAA) and Society Automotive Engineers (SAE) publications note that for proper clamping action at least three threads should show above the nut. FAA publication AC 43.12 notes that screws and bolts should ideally be put in from the top down when at all possible to prevent the effects of gravity and vibration from loosening the fasteners. During an on scene examination of the airplane, the FAA inspector found the attaching screw and collar from the left control wheel on the floor. The inspector moved the left control wheel and found that the column would not move. He moved the column and verified aileron continuity. Post accident examination of the control wheel attachment screw, and several others from the same make and model airplane, revealed that there was a slight difference in length between them all. It was also noted that some had different letter markings on the screw head. On average, when the screws were fully torqued, between 1 and 1 1/2 threads were exposed beyond the top of the nut plate. The torque of the fastenings was checked on all 35 Pipers in the operators fleet, which consists of 19 PA-28-181's and 11 PA-44-180's. Ten control wheel screws were found to be loose. The screws turned 1/8 to 1/4 revolution before coming up to torque. A number of other flight schools were contacted, and all found loose screws that required a 1/8 to 1/4 revolution turn before coming up to torque. ## Factual narrative On July 7, 2003, at 1256 mountain standard time, a Piper PA-28-181, N288PA, collided with a tree during an emergency landing 18 miles northeast of Phoenix Deer Valley Airport (DVT), Phoenix, Arizona. The emergency landing was precipitated by a loss of aileron and elevator control while maneuvering. Pan Am International Flight Academy, Phoenix, operated the airplane under the provisions of 14 CFR Part 91 as an instructional flight. The private pilot, the sole occupant, was not injured; the airplane sustained substantial damage. The local flight departed DVT about 1215. Visual meteorological conditions prevailed, and a flight plan had not been filed. During an interview with the National Transportation Safety Board investigator-in-charge (IIC), the pilot, who was working toward his commercial certificate, stated that he departed DVT about 1215 to practice maneuvers. He attempted to make a clearing turn at 5,000 feet above ground level (agl) by moving the control wheel to the right, but the airplane did not respond. He looked at the wing as he continued moving the control wheel and realized that the ailerons were not operating. The pilot immediately contacted Deer Valley tower and declared an emergency. He landed the airplane on a dirt road using rudder and throttle to control movement. During the landing, the right wing impacted a tree. The wing was displaced upwards, blocking the cabin door and baggage door from opening. The door assembly was removed at the hinges by a pedestrian in order to evacuate the pilot. The design of the control wheel to control column interface utilizes a nut plate installed inside the column. A screw and collar are then inserted through the bottom of the control wheel and into the nut plate inside the column to secure it to the column. Various Federal Aviation Administration (FAA) and Society of Automotive Engineers (SAE) publications note that for proper clamping action at least three threads should show above the nut. FAA publication AC 43.12 notes that screws and bolts should ideally be put in from the top down when at all possible to prevent the effects of gravity and vibration from loosening the fasteners. During an on scene examination of the airplane, the FAA inspector found the attaching screw and nut plate from the left control wheel on the floor. The screw and nut plate attaches the control wheel to the control column. The head of the screw was painted and did not appear to have been removed by a screwdriver. The inspector moved the left control wheel and found that the column would not move. He moved the column and verified aileron continuity. He also noted excess oil on the control column. The left screw was installed and then removed with a screwdriver. The marking on the head of the left screw was "X and F." The right control wheel assembly was checked for tightness using a screwdriver. The screw turned in the direction of tightening about 1/4 turn before it became fully torqued. The marking on the head of the right screw was "X and F." A post accident investigation was performed at Pan Am International Flight Academy in Phoenix under the supervision of an FAA inspector. According to the manufacturer's representative, the left control wheel was reassembled and the screw was tightened with a screwdriver. About one thread was exposed above the nut plate. The screw was tightened, and only minor resistance was felt as it entered the nut plate. The screw was measured using a ruler and a micrometer. The ruler indicated that the screw was about 1 1/16 inches in length. The micrometer indicated that the screw was 1.0875 inches in length. The right screw was removed and measured using a ruler and micrometer. The ruler indicated that the screw was about 1 1/16 inches long. The micrometer indicated that the screw was 1.088 inches in length. It was then installed into the nut plate and tightened using hand force. A portion of the thread of the screw was exposed beyond the top of the nut plate. The control wheel was reassembled and the screw was tightened with a screwdriver. About one thread was exposed beyond the top of the nut plate. Using a new screw and nut plate, the screw was threaded into the nut plate and tightened by hand. The screw did not protrude through the nut plate before the locking force exceeded the hand torque. For comparison, both control wheel covers were removed from another PA-28-181, Serial Number (S/N) 28-43307, and the thread engagement was visually checked. About 1 1/2 threads were exposed beyond the top of the nut plate. The screw from the left control wheel assembly was removed and measured using a micrometer. The ruler indicated that the screw was about 1 3/32 inches in length. The micrometer indicated that the screw was 1.104 inches in length. The markings on the head of the screws were "X and MAC." The left control wheel covers were removed from three other PA-28-181's; S/N's 28-43500, S/N 28-43499, and S/N 28-43306. All three exhibited about one thread exposed beyond the nut plate, and the screws required additional turns to fully tighten. The markings on the head of all three screws were "F and X." According to the Director of Maintenance for Pan Am International Flight Academy, the torque of the fastenings was checked on all 35 Pipers in their fleet. Their fleet consists of 19 PA-28-181's and 11 PA-44-180's. Ten control wheel screws were found to be loose. The screws turned 1/8 to 1/4 revolution before coming up to torque. The director contacted four other flight schools and was told that they also had found loose screws that required 1/8 to 1/4 revolution turns before coming up to torque. ## Aircraft - Registration: [N288PA](https://openairdocs.org/aircraft/N288PA), registered now, S/N 2843502, built 2002 (OpenAirDocs) - Reported make and model: Piper PA-28-181 - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming O-360 series](https://openairdocs.org/engine/lycoming-o-360-series) (registry code 41575, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2843502 - Airframe hours: 1802.02 - Engines: Lycoming O-360-A4M 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Pan Am International Flight Academy, doing business as Pan Am International Flight Academy - Registered owner: Merrill Lynch Business Financial Services Inc. - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, July 5, 2003, 1.9 hours before - Departed: DVT, Phoenix, AZ - Destination: DVT, Phoenix, AZ ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review May 12, 2003; seat: left; flight hours: 180 total, 180 in this make and model, 94 as pilot in command, 69 in the last 90 days, 15 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 100 °F, dew point 50 °F - Altimeter: 29.79 inHg - Observed at: DVT, 18 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 20030707016779A](https://openairdocs.org/incident/20030707016779A), Jul 7, 2003: Piper PA28181, Scottsdale, AZ, Substantial damage. (-23) Pilot was conducting practice flights for his commercial rating when he lost aileron control. The control wheel moved but had no effect on the ailerons,… ## Other investigations on N288PA (1) 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. - [NTSB GAA17CA189](https://openairdocs.org/ntsb/GAA17CA189), Mar 12, 2017: Piper PA 28 (N288PA), Gila Bend, AZ, substantial damage. Probable cause: The flight instructor’s failure to review the notices to airmen related to the airport, which resulted in his landing on a closed runway and the airplane striking runway closed markers. 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.