# NTSB MIA01IA091: Cessna 402C, N108GP, Fort Lauderdale, FL, March 3, 2001 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: March 3, 2001, 14:52 local (19:52 UTC) - Place: Fort Lauderdale, FL - Coordinates: 26.072778, -80.152778 - Nearby events: https://openairdocs.org/map.md?lat=26.0728&lon=-80.1528&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 9 uninjured - Status: Completed, report November 28, 2001 - Report: Approved by Office Director - Parties: FAA Flight Standards District Office - NTSB case key (mKey): 51867 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA01IA091 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/51867/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=51867 - Page: https://openairdocs.org/ntsb/MIA01IA091 ## Probable cause Incomplete compliance with a non-mandatory Cessna Service Information Letter by an unknown person resulting in pulling through of the attach bolt of the upper and lower link assemblies and subsequent rotation of the right wheel assembly. Additionally, improper overhaul of the right main landing gear actuator by an unknown person resulting in collapse of the right main landing gear. Findings in the investigation were: 1) Inadequate compliance with a Cessna Service Bulletin (SB) by company maintenance personnel for failure to replace the actuator as addressed in the SB due to a discrepancy with the actuator noted during the post incident testing, and 2) Failure of the FAA to include inspection of the main landing gear torque links in the FAA approved inspection program as described in the Cessna Progressive Care Program. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Main gear collapsed, landing - roll - maintenance,service bulletin/letter - not complied with, company maintenance personnel - landing gear,main gear strut scissors - separation (cause) - maintenance,overhaul - improper, unknown (cause) - landing gear,normal retraction/extension assembly - unlocked - maintenance,service bulletin/letter - not complied with, company maintenance personnel ## Analysis The pilot reported that during the approach to runway 27L with the wind from the southwest at 15 knots and no gusts, he confirmed that all gears were down and locked as evidenced by the down and locked lights. He reported landing first on the left main landing gear followed by the right main then nose gear. During the landing roll while almost stopped, "I felt like a blown tire, right wheel zig zag and suddenly I could not control turn to the right and landing gear collapse." The airplane came to rest upright; scrubbing was noted on the lower inboard portion of the right main landing gear tire and the right main landing gear wheel assembly was rotated nearly 90 degrees. Additionally, the upper and lower link assemblies of the right main landing gear were separated from each other; the attach hardware for them remained in the upper link assembly. Post incident examination of the airplane revealed that the bolt that secures the upper and lower link assemblies pulled through the lower link assembly on the nut end. Two washers on the nut end with a thickness of approximately .023 inch were damaged during the pull-through. A washer with a thickness of approximately .061 was installed under the bolt head. A non-mandatory Cessna Service Information Letter indicates to install .066 inch thick washers on the head and nut end of the bolt that secures the upper and lower link assemblies. There was no record in the maintenance records that the non-mandatory service information letter was complied with. Post incident testing of the right main landing gear actuator revealed that the unlocking pressure was too high and one of the four lock keys was improperly installed. Testing of the right main landing gear actuator for unlock pressure was performed by the operator approximately 2 months before the incident in accordance with a service bulletin (SB). The SB states to replace the actuator if the unlocking pressure is not in specification; the actuator was not replaced. There was no serviceable tag in the maintenance records and no determination was made indicating when or what facility overhauled the actuator. The FAA approved inspection program for the operator does not list to inspect the main landing gear link assemblies as does the Cessna Progressive Care Program. ## Factual narrative On March 3, 2001, about 1452 eastern standard time, a Cessna 402C, N108GP, registered to a private individual, leased to and operated by Safe Air International, Inc., dba Island Express as Sandy Isle Flight 108, experienced a loss of directional control and subsequent collapse of the right main landing gear during the landing roll at the Fort Lauderdale/Hollywood International Airport, Fort Lauderdale, Florida. Visual meteorological conditions prevailed at the time and a defense visual flight rules (DVFR) flight plan was filed and activated for the 14 CFR Part 135 scheduled, international, passenger flight. The airplane sustained minor damage and there were no reported injuries to the airline transport-rated pilot or eight passengers. The flight originated about 1352, from Marsh Harbor, Bahamas. The pilot stated that during the approach to runway 27L, all gears were extended and locked as evidence by illumination of the gear down and locked lights. He reported that the wind was from the southwest at 15 knots with no gusts and touched first with the left main landing gear followed by the right main then nose landing gear. During the landing roll while almost stopped, "I felt like a blown tire, right wheel zig zag and suddenly I could not control turn to the right and landing gear collapse." The airplane came to rest upright (See photograph 1); minor damage was noted to the right wing tip. During recovery of the airplane, the right main landing gear wheel assembly was noted to be rotated nearly 90 degrees (See photograph 2). Additionally, the upper and lower link assemblies were separated from each other; the attach hardware for them remained in the upper link assembly. Examination of the airplane by an Federal Aviation Administration (FAA) airworthiness inspector revealed a AN175-20 bolt with attached castellated nut and associated washers and bushing pulled through the lower link assemby of the right main gear on the nut end of the bolt. Additionally, the inboard lower portion of the right main landing gear tire exhibited evidence of scrubbing due to contact with the ground (See photographs 3 and 4). The bolt and associated hardware (See photograph 5), and the right main landing gear actuator were retained for further examination. A copy of the FAA inspector statement is an attachment to this report. The right main landing gear actuator was manufactured by Teijin Seiki Company, Ltd., as part number 1521200-9. Bench testing of the actuator revealed the unlocking pressure was greater than specified when tested 5 separated times; the unlocking pressure measured between 450 and 525 psi. The specified unlocking pressure is between 250 and 400 psi. No leaks were noted during the pressure testing. Disassembly of the actuator revealed that one of the four lock keys (part number (P/N) 1521210-5) was improperly installed (See photograph 6), resulting in a rolled edge on the inside diameter of the cylinder end P/N 1521203-1 (See photograph 7). Additionally the cylinder end was not bottomed on the cylinder barrel P/N 1521201-3) per instructions found in the overhaul manual; according to repair station personnel this had no effect. An excerpt from the maintenance manual depicting the correct installation of the lock key is an attachment to this report. Cessna Service Bulletin MEB91-12, dated December 20, 1991, pertaining to functional testing of landing gear actuators with a mandatory accomplishment every 12 months, indicates in part, "Replace actuator if it does not meet the unlock pressure requirement...." The service bulletin was accomplished last on December 29, 2000, as depicted in a Service Bulletin Compliance Record. Copies of the service bulletin and the Service Bulletin Compliance Record are attachments to this report. Examination of the retained bolt and attached hardware by the NTSB revealed the outside diameter of two washers that were installed on the nut end of the bolt were reduced/failed; and exhibited evidence of being bent towards the castellated nut (See Photograph 8). The washers measured approximately .023 inch thick (See photographs 9 and 10). The washer that was installed beneath the bolt head measured approximately .061 inch thick (See photograph 11). Cessna Service Information Letter ME83-37, dated November 23, 1983, titled, "Main Landing Gear Scissor Washer Replacement", which is non-mandatory, recommends to replace the two outer washers on the main landing gear scissor link for improved service life and main gear wheel alignment retention. There was no record of compliance with the non-mandatory service information letter in the maintenance records. The thickness of a washer specified in the service information letter is approximately .065 inch (See photograph 12). A copy of the service information letter is an attachment to this report. Review of the maintenance records by the FAA airworthiness inspector revealed no serviceable tag for the incident actuator. The actuator was installed in the airplane on August 3, 1996, and had accumulated 5,993.4 hours and approximately 4,500 cycles since installation at the time of the incident. The landing gear was rigged and operationally checked last on October 21, 2000, which is accomplished every 400 hours or 12 months; the airplane had accumulated approximately 345 hours since then at the time of the incident. The landing gear which is inspected every 180 hours during a "C" check, was signed off last on February 11, 2001. The airplane had accumulated approximately 76 hours since the inspection at the time of the incident. The Cessna Progressive Care Program does mention to inspect the main landing gear torque links; however, the FAA approved inspection program for the operator does not mention to inspect the main landing gear torque links. A copy of the FAA approved "C" inspection performed last, excerpts from the maintenance records, and an excerpt from the Cessna Progressive Care Program are attachments to this report. The airplane minus the NTSB retained right main landing gear actuator was released to the airplane owner, Dave Bettencourt, on March 23, 2001. The retained right main landing gear actuator was released to Mayra A. Horna, Secretary and Treasurer for Island Express, on October 23, 2001. ## Aircraft - Registration: N108GP (not matched to a registry record) - Reported make and model: Cessna 402C - Category: Airplane - Serial number: 402C0058 - Airframe hours: 22092 - Engines: Continental TSIO-520-VB 325 horsepower reciprocating - Damage: Minor damage - Flight: Part 135 - Operator: Safe Air International, Inc., doing business as Island Express - Registered owner: Kissonai Bettencourt - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, February 20, 2001, 41 hours before - Departed: MYAT, Marsh Harbor - Destination: KFLL, Fort Lauderdale, FL - Flight plan: VFR - Airport: FLL, Fort Lauderdale/Hollywood Intl, runway 27L, 5,276 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: none; commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; last flight review January 1, 2001; seat: left; flight hours: 21,000 total, 4,500 in this make and model, 19,000 as pilot in command, 180 in the last 90 days, 91 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 16 knots, gusting 20 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 66 °F - Altimeter: 29.87 inHg - Observed at: KFLL ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Incident 20010303009609I](https://openairdocs.org/incident/20010303009609I), Mar 3, 2001: Cessna 402C, Ft Lauderdale, FL, Minor damage. (-23)Aircraft landed at fll on runway 27L, and on roll prior to taxiway G2, the right main landing gear collapsed and aircraft ran off pavement. The thru bolt… ## Docket (28 files) The files NTSB released with the investigation on November 13, 2001, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=51867. 4.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 524 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413632&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Supplement S (item 2, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149817&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Statements from Luciano Horna (item 3, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413633&FileExtension=.PDF&FileName=Statements%20from%20Luciano%20Horna-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 4, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413634&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1: View of the airplane where it came to rest. No negative. (item 5, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149820&FileExtension=.PDF&FileName=Photo%201%3A%20View%20of%20the%20airplane%20where%20it%20came%20to%20rest.%20%20No%20negative.-Master.PDF - Photo 2: View of the right main landing gear wheel assembly showing the 90 degree rotation. No negative. (item 6, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149821&FileExtension=.PDF&FileName=Photo%202%3A%20View%20of%20the%20right%20main%20landing%20gear%20wheel%20assembly%20showing%20the%2090%20degree%20rotation.%20%20No%20negative.-Master.PDF - Photo 3: View of the right wheel assembly. Note the scrubbing on the lower inboard surface of the tire. No negative. (item 7, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149822&FileExtension=.PDF&FileName=Photo%203%3A%20View%20of%20the%20right%20wheel%20assembly.%20%20Note%20the%20scrubbing%20on%20the%20lower%20inboard%20surface%20of%20the%20tire.%20%20No%20negative.-Master.PDF - Photo 4: View of the right wheel assembly. Note the scrubbing on the lower inboard portion of the tire. No negative. (item 8, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149823&FileExtension=.PDF&FileName=Photo%204%3A%20View%20of%20the%20right%20wheel%20assembly.%20%20Note%20the%20scrubbing%20on%20the%20lower%20inboard%20portion%20of%20the%20tire.%20%20No%20negative.-Master.PDF - Photo 5: Digital photograph. View of the upper and lower link assembly attach hardware that was recovered. (item 9, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149824&FileExtension=.PDF&FileName=Photo%205%3A%20Digital%20photograph.%20%20View%20of%20the%20upper%20and%20lower%20link%20assembly%20attach%20hardware%20that%20was%20recovered.-Master.PDF - Photo 6: Digital photograph. View of the incorrectly installed lock key in the right main landing gear actuator. (item 10, .PDF, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149825&FileExtension=.PDF&FileName=Photo%206%3A%20Digital%20photograph.%20%20View%20of%20the%20incorrectly%20installed%20lock%20key%20in%20the%20right%20main%20landing%20gear%20actuator.-Master.PDF - Photo 7: Digital photograph. View of the damage on the inside diameter of the cylinder end. (item 11, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149826&FileExtension=.PDF&FileName=Photo%207%3A%20Digital%20photograph.%20%20View%20of%20the%20damage%20on%20the%20inside%20diameter%20of%20the%20cylinder%20end.-Master.PDF - Photo 8: Digital photograph. View of the two washers that were installed on the nut end of the bolt. Note the bending damage. (item 12, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149827&FileExtension=.PDF&FileName=Photo%208%3A%20Digital%20photograph.%20%20View%20of%20the%20two%20washers%20that%20were%20installed%20on%20the%20nut%20end%20of%20the%20bolt.%20%20Note%20the%20bending%20damage.-Master.PDF - Photo 9: Digital photograph. View of the measurement of one of the washers that was installed on the nut end of the bolt. (item 13, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149828&FileExtension=.PDF&FileName=Photo%209%3A%20Digital%20photograph.%20%20View%20of%20the%20measurement%20of%20one%20of%20the%20washers%20that%20was%20installed%20on%20the%20nut%20end%20of%20the%20bolt.-Master.PDF - Photo 10: Digital photograph. View of the measurement of the other washer installed on the nut end of the bolt. (item 14, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149829&FileExtension=.PDF&FileName=Photo%2010%3A%20Digital%20photograph.%20%20View%20of%20the%20measurement%20of%20the%20other%20washer%20installed%20on%20the%20nut%20end%20of%20the%20bolt.-Master.PDF - Photo 11: Digital photograph. View of the measurement of the washer that was installed beneath the bolt head. (item 15, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149830&FileExtension=.PDF&FileName=Photo%2011%3A%20Digital%20photograph.%20%20View%20of%20the%20measurement%20of%20the%20washer%20that%20was%20installed%20beneath%20the%20bolt%20head.-Master.PDF - Photo 12: Digital photograph. View of the measurement of the washer specified in Cessna Service Information Letter ME83-37. (item 16, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149831&FileExtension=.PDF&FileName=Photo%2012%3A%20Digital%20photograph.%20%20View%20of%20the%20measurement%20of%20the%20washer%20specified%20in%20Cessna%20Service%20Information%20Letter%20ME83-37.-Master.PDF - Reports from Federal Agencies-FAA (item 17, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149832&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies-FAA-Master.PDF - Excerpts from the Illustrated Parts Catalog depicting the main landing gear actuator (Item 225). (item 18, .PDF, 131 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149833&FileExtension=.PDF&FileName=Excerpts%20from%20the%20Illustrated%20Parts%20Catalog%20depicting%20the%20main%20landing%20gear%20actuator%20(Item%20225).-Master.PDF - Excerpts from the Illustrated Parts Catalog showing the bolt (Item 105) that pulled through the upper (Item 94) and lower (Item 96) link assemblies. (item 19, .PDF, 134 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149834&FileExtension=.PDF&FileName=Excerpts%20from%20the%20Illustrated%20Parts%20Catalog%20showing%20the%20bolt%20(Item%20105)%20that%20pulled%20through%20the%20upper%20(Item%2094)%20and%20lower%20(Item%2096)%20link%20assemblies.-Master.PDF - Excerpts from the Maintenance Manual with Parts List for the main landing gear actuator. (item 20, .PDF, 299 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149835&FileExtension=.PDF&FileName=Excerpts%20from%20the%20Maintenance%20Manual%20with%20Parts%20List%20for%20the%20main%20landing%20gear%20actuator.-Master.PDF - Excerpt from the actuator maintenance manual with figure 703 depicting the correct installation of the lock key. (item 21, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149836&FileExtension=.PDF&FileName=Excerpt%20from%20the%20actuator%20maintenance%20manual%20with%20figure%20703%20depicting%20the%20correct%20installation%20of%20the%20lock%20key.-Master.PDF - Excerpts from the Maintenance Records (item 22, .PDF, 421 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413635&FileExtension=.PDF&FileName=Excerpts%20from%20the%20Maintenance%20Records-Redacted.PDF - Recurring Service Bulletin Compliance Record for MEB91-12 (item 23, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413636&FileExtension=.PDF&FileName=Recurring%20Service%20Bulletin%20Compliance%20Record%20for%20MEB91-12-Redacted.PDF - Cessna Service Bulletin MEB91-12 (item 24, .PDF, 249 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149839&FileExtension=.PDF&FileName=Cessna%20Service%20Bulletin%20MEB91-12-Master.PDF - Latest "C" Inspection Form (item 25, .PDF, 693 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413637&FileExtension=.PDF&FileName=Latest%20%22C%22%20Inspection%20Form-Redacted.PDF - Excerpt from the Cessna Progressive Care Program (item 26, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149841&FileExtension=.PDF&FileName=Excerpt%20from%20the%20Cessna%20Progressive%20Care%20Program-Master.PDF - Cessna Service Information Letter ME83-37 and Service Kit SK421-118 (item 27, .PDF, 300 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40149842&FileExtension=.PDF&FileName=Cessna%20Service%20Information%20Letter%20ME83-37%20and%20Service%20Kit%20SK421-118-Master.PDF - March 3, 2001 Aircraft Flight and Maintenance Log (item 28, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413638&FileExtension=.PDF&FileName=March%203,%202001%20Aircraft%20Flight%20and%20Maintenance%20Log-Redacted.PDF From the NTSB's public API. 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