MIA08LA187

NTSB accident investigation · Piper J5A · Atlanta, GA · September 7, 2008

Accident · No injuriesLimited investigationFinal report
Date
September 7, 2008, 14:00 local (18:00 UTC)
Place
Atlanta, GA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N105FPiper J5A
Defining event
Maneuvering-low-alt flying: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report June 17, 2010
Report
Approved by Office Director
Parties
FSDO/FAA
FAA report
20080907855299A
Case key
68888

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

The loss of pitch control due to slippage of the elevator control cable resulting from the maintenance personnel’s improper installation and inspection of the cable.

Findings · 3

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.

Inspection: post maintenance inspectionPersonnel issues › Task performance · Maintenance personnelPiper J5A: 1 caseAll aircraft: 57 casesProbable cause
Flight control system: elevator control systemAircraft › Aircraft systems · Incorrect service/maintenancePiper J5A: 1 caseAll aircraft: 74 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

During a banner-pick up maneuver, the pilot “heard and felt a pop from the elevator cable.” The airplane leveled off with the flight control stick in the full-aft position, and the elevator was in the neutral position. The airplane continued in an uncontrollable slight descent into a rough field where the airplane impacted with the ground. Wreckage examination revealed the cable for the elevator's, pitch-up control, located at the lower end of the control stick through the attaching thimble, had slipped through the cable oval sleeve swage. Examination by the NTSB Material Laboratory of the swage revealed the incorrect grooves on the hand tool was used to crimp the swage. The operator was not utilizing a “go–no go” gauge to insure proper crimping of the oval sleeve swage. Several airplanes in the operator’s 27 airplane fleet had flight control cable fabricated and replaced by their maintenance personnel. The operator grounded its fleet and conducted an inspection of flight control cable assemblies. A total of 36 flight control cable swages and 41 flight control cables were required to be replaced.

Factual narrative

On September 7, 2008, at 1400 central daylight time, a Piper J5A, N105F, operated by Van Wagner Aerial Media, LLC, incurred substantial damage when it impacted terrain during a banner towing flight in Atlanta, Georgia. Visual meteorological conditions prevailed and a company flight plan was filed for the Title 14 Code of Federal Regulations Part 91, flight. The pilot received minor injuries. The pilot stated that he had flown 3 hours that day in the same airplane prior to the accident. During his second schedule flight, he took off and executed the banner pick up maneuver; however, missed the pick up. The pilot flew back into the pattern and maneuvered for another attempt at the pick up. At the pull up maneuver, a 30 degrees nose up pitch at full engine power, the pilot “heard and felt a pop from the elevator cable.” The airplane leveled off and he reduced the engine power. With the flight control stick in the full aft position, he observed the elevator was in the neutral position. He reached behind his seat and pulled on the elevator control cable lightly. The airplane transitioned into a slight nose down attitude. He pulled on the other elevator cable and did not feel any resistance “loose cable” or any change in pitch attitude. The pilot continued an uncontrollable slight descent into a rough field where the airplane impacted with the ground. The pilot was able to exit the airplane without assistance. A controller at the airport’s control tower stated that he heard over the speaker, N105F declaring an emergency and observed the airplane airborne westbound between runway 27 and the north run-up area. The controller observed the airplane slowly descend westbound and disappeared behind the tree lines, approximately 500 feet west of the departure end of runway 27. The pilot holds a commercial pilot certificate with airplane single engine land and instrument airplane ratings., He holds a private pilot certificate with an airplane multiengine land rating. He was issued a second-class medical certificate in December of 2007, with no limitation. The pilot reported a total flight experience of 909 hours. A wreckage examination by a Federal Aviation Administration inspector revealed that the cable for the elevator, nose pitch up control, located at the lower end of the control stick through the attaching thimble, had slipped through the oval sleeve cable swage. The control stick, elevator up and down pitch control cable assemblies, along with the operator’s cable swage hand tools, and exemplars from the operator’s stock flight control cable fabrication hardware were retained; and sent to the National Transportation Safety Board Material Laboratory for further examination. The examination of the components submitted to the material laboratory revealed that the swage for the elevator control cable, located at the lower end of the control stick through thimble, were incorrectly process; the incorrect grooves on the hand tool was used to crimp the ovalsleeve swage. The crimps at the other ends of the elevator cables were observed properly swage. The operator did not utilized the “go-no go” sleeve gauge after each swage to confirm proper processing. The accident airplane, along with several other airplanes in the operator’s fleet, had flight control cable replacements, which the operator fabricated in house. The operator grounded their fleet immediately after the accident. A re-inspection of all flight control cables and flight control swages was conducted among the operator’s 27 airplanes. A total of 36 flight control cable swages and a total of 41 flight control cables were replaced. The operator implemented a new quality assurance procedure for in house flight control cable fabricating.

Aircraft

Registration
N105F
Reported as
Piper J5A
Category
Airplane
Serial number
5-477
Airframe hours
12,490
Engine
Lycoming O-360-C2A, 180 hp, reciprocating
Damage
Substantial damage
Flight
Banner tow · Part 91
Operator
Van Wagner Aerial Media LLC
Registered owner
Van Wagner Aerial Media LLC
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · August 8, 2008 · 90 hours before
Departed
FTY · Atlanta, FL
Destination
FTY · Atlanta, FL
Flight plan
Company VFR
Airport
FTY · Fulton County Airport

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
19
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
November 26, 2007
Seat
Front
Flight hours
909 total · 73 in this make and model · 290 in the last 90 days · 110 in the last 30 days · 7 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 64 °F
Altimeter
30.04 inHg
Observed at
FTY

Docket · 9

The files NTSB released with the investigation on April 13, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.2 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.