# NTSB MIA06LA002: Piper PA-46-350P, N9199P, Destin, FL, October 3, 2005 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: October 3, 2005, 12:05 local (17:05 UTC) - Place: Destin, FL - Coordinates: 30.399999, -86.469444 - Nearby events: https://openairdocs.org/map.md?lat=30.4000&lon=-86.4694&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report September 27, 2007 - Report: Approved by Office Director - Parties: FAA FSDO - NTSB case key (mKey): 62632 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA06LA002 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/62632/pdf - Page: https://openairdocs.org/ntsb/MIA06LA002 ## Probable cause The inadequate design of the engine mount which led to cracking of the mount resulting in a loss of directional control and collapse of the nose landing gear. A contributing factor was the failure of maintenance personnel to comply with a service bulletin to inspect the engine mount for cracks. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, landing - roll - maintenance,service bulletin/letter - not complied with, other maintenance personnel (contributing factor) - acft/equip,inadequate design, manufacturer (cause) - engine assembly,mount - cracked - landing gear,nose gear attach point - separation - Loss of control - on ground/water, landing - roll - directional control - not possible, pilot in command - Nose gear collapsed, landing - roll ## Analysis The pilot reported that the landing seemed normal for a few seconds, and then the airplane started to swerve to the right. He tried to compensate with the application of hard left brake and full left aileron, but the airplane continued swerving to the right and departed the runway. The nose gear collapsed, and the airplane then slid approximately 300 feet on the main landing gear and the underside of the cowling before coming to a stop. Examination of the airplane revealed that the engine mount was fractured at the right nose gear actuator attach foot. Rust was visible on the fracture surface, indicating the crack was pre-existing. The crack was in the area that was the subject of a Piper Service Bulletin. The Service Bulletin required operators to inspect the engine mounts for cracks after every 100 hours of flight time, until the engine mount was replaced with a newer model which incorporated one-piece feet at the nose gear actuator attach points. The engine mount installed in the airplane was the original Piper design configuration (two-piece welded foot design). Review of the airplane's maintenance records indicated that the Service Bulletin had not been complied with at the most recent annual inspection conducted 89.1 flight hours prior to the accident. ## Factual narrative On October 3, 2005, about 1205 central daylight time, a Piper PA-46-350P, N9199P, registered to Lookout Leasing Co. and operated by an individual as a Title 14 CFR Part 91 personal flight, veered off the runway during the landing roll at the Destin-Fort Walton Beach Airport, Destin, Florida. The private pilot and the passenger reported no injuries, and the airplane incurred substantial damage. Visual meteorological conditions prevailed at the time and location of the accident, and an instrument flight rules (IFR) flight plan was filed. The flight originated from the Lovell Field Airport, Chattanooga, Tennessee, about 1015. The pilot reported that the flight from Chattanooga to Destin was uneventful, and about 5 miles out from the airport, he canceled the IFR flight plan. He obtained weather information from the airport's automated surface observation system and elected to land on runway 14. The landing seemed normal for a few seconds, and then the airplane started to swerve to the right. The pilot further stated that the airplane pulled harder to the right as it slowed down, and that he tried to compensate with the application of hard left brake and full left aileron, but the airplane continued swerving to the right and departed the runway. The nose gear collapsed before the airplane came to a stop. A witness stated that he watched the airplane during the last portion of its approach and that it appeared to be a normal landing. After touchdown, the airplane began to drift to the right and only traveled a short distance, before the nose wheel struck the grass. The nose wheel immediately collapsed, and the propeller blades struck the ground and stopped. The aircraft then slid approximately 300 feet on the main landing gear and the underside of the cowling before coming to a stop. Examination of the airplane revealed that the firewall was wrinkled. Additionally, the mechanic who performed the examination noted that the engine mount was fractured at the right nose gear actuator attach foot. The mechanic reported that rust was visible on the fracture surface, indicating the crack was pre-existing. Piper Service Bulletin (SB) 1103, Engine Mount Inspection, was issued on April 22, 2002. The SB was updated on January 27, 2003 (1103A) and again on November 25, 2003 (1103B). The SB contained the following information. Purpose: It has been determined that cracks may develop on the engine mount in the area of the nose gear actuator feet. This condition typically occurs when the nose landing gear is subjected to excessive loads, possibly through hard landings, rough field operations, excessive speed turns and/or improper towing of the aircraft. PART I of this SB requires a repetitive inspection of the engine mount. PART II of this SB requires replacement of the engine mount. Compliance Time: PART I Inspection to coincide with the next regularly scheduled maintenance event, and each 100 hours time in service or annual inspection, whichever occurs first, thereafter or until PART II of this SB is accomplished. PART II Replacement if cracks are found during the inspection in PART I, replace cracked engine mount. Note: Compliance with PART II of this SB will relieve the repetitive inspection requirements of PART I of this SB. PART II: Insure the new engine mount (P/N 89137-041) has the one piece feet. The old engine mount has a two piece welded foot. This welded area is where the cracks in the engine mounts have been found. Review of the airplane's maintenance records revealed that during an annual inspection in January 2002, the engine mount was "found cracked at the lower actuator attachment point" and replaced with an overhauled engine mount. The overhauled engine mount had been repaired to the original Piper design configuration (two piece welded foot design) by a certified repair station. The most recent annual inspection was performed on January 14, 2005. As of that date, the airframe had accumulated 3,009.6 hours. The logbook entry for this annual inspection did not indicate compliance with SB 1103B Part I. Review of the checklist used by the facility that performed the annual inspection revealed that it was the 100-hour periodic inspection checklist from the Piper PA-46-310P/350P Maintenance Manual. Under the Engine Group section of the checklist, item 43, "Inspect engine mounts for cracks, corrosion, and loose mounting bolts," was initialed as complete. Under the General section of the checklist, item 2, "All Airworthiness Directives, Service Bulletins, Letters and Instructions complied with," was initialed as complete; however, the portion of this item reading, "Service Bulletins, Letters and Instructions complied with," was crossed out. At the time of the accident, the airplane had accumulated 89.1 hours since the annual inspection. ## Aircraft - Registration: [N9199P](https://openairdocs.org/aircraft/N9199P), registered now, S/N 4622107, built 1990 (OpenAirDocs) - Reported make and model: Piper PA-46-350P - Registry model: [Piper PA 46-350P](https://openairdocs.org/model/piper-pa-46-350p) (registry code 7104620) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 4622107 - Airframe hours: 3099.1 - Engines: Lycoming TIO-540-AE2A 350 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 1, 2005, 89.1 hours before - Departed: KCHA, Chattanooga, TN - Destination: KDTS, Destin, FL - Flight plan: IFR - Airport: KDTS, Destin-Fort Walton Beach, runway 14, 4,999 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: none; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review October 1, 2004; seat: left; flight hours: 4,035 total, 1,536 in this make and model, 4,107 as pilot in command, 29 in the last 90 days, 8 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 80° at 11 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 70 °F - Altimeter: 30.09 inHg - Observed at: DTS ## 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 20051003022929A](https://openairdocs.org/incident/20051003022929A), Oct 3, 2005: Piper PA46350P, Destin, FL, Substantial damage. (-23) Pilot in command stated that during crosswind landing roll out, right brake would not release after application during crosswind procedure. Post accident… 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.