SEA04TA147

NTSB accident investigation · WSK PZL Mielec M-18A · Burns, OR · July 26, 2004

Accident · No injuriesFinal report
Date
July 26, 2004, 13:26 local (20:26 UTC)
Place
Burns, OR
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N495WPWSK PZL Mielec M-18A
Weather
Visual (VMC) · Day
Status
Completed · report October 28, 2004
Report
Approved by Office Director
Parties
FAA FSDO
Case key
59810

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The improper installation of the throttle linkage clevis to the throttle control arm by unknown maintenance personnel. Contributing factors were the nylon lock nut separating from its' bolt, which permitted the throttle cable to disconnect from the throttle control arm, and the fence post.

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.

Airframe/component/system failure/malfunctionManeuvering - aerial application
Maintenance,installation - improperOther maintenance personnelCause
Throttle/power lever,cable - disconnectedFactor
Loss of engine power(partial) - mech failure/malfClimb - to cruise
Forced landingEmergency descent/landing
On ground/water collision with objectLanding - roll
Object - fence postFactor

Analysis

The pilot was attempting to climb following a fire retardant drop. When he moved the throttle forward, the engine did not respond. The airplane started loosing altitude, and the pilot performed a forced landing to an open plateau. During the landing, the throttle would not retard all the way. In order to land the airplane, the pilot turned the fuel selector to the off position. During the landing roll, the left wing impacted a fence pole bending ribs and wrinkling the aileron. Post accident examination revealed that the bolt normally connecting the throttle linkage clevis to the throttle arm was missing. The investigating team examined a sister aircraft from the same provider. They found that a nylon lock nut had been installed on the clevis bolt, and it was loose enough to be removed without the aid of any tools. The industry standard, found in FAA Advisory Circular AC43.13-1B, chapter 7, section 4, paragraph 7-64, states that nylon locking nuts should not be used with rotating components or assemblies. It further states that nylon and/or fiber nuts are highly susceptible to wear from repetitive use and from high heat applications.

Factual narrative

On July 26, 2004, at 1326 Pacific daylight time, a WSK PZL Mielec M-18A [Dromader], N495WP, was substantially damaged when it struck a fence post during a forced landing attempt near Burns, Oregon. The commercial pilot was not injured. Western Pilot Service Inc., Maricopa, Arizona, was operating the aircraft for the United States Department of Agriculture, United States Forest Service. Visual meteorological conditions prevailed for the fire retardant application flight that originated approximately 20 minutes before the accident. A company VFR flight plan was on file.

The pilot reported that he was attempting to climb following a retardant drop. When he moved the throttle forward, the engine did not respond. He said the airplane started loosing altitude, and pumping the throttle had no effect. The pilot saw a plateau just southwest of the fire, and he performed a forced landing to it. During the landing, the throttle would not retard all the way. In order to land the airplane where he wanted to, he turned the fuel selector to the off position. During the landing roll, the left wing impacted a fence pole bending ribs and wrinkling the aileron.

Post accident examination revealed that the bolt normally connecting the throttle linkage clevis to the throttle arm was missing. The investigating team examined a sister aircraft from the same provider. They found that a nylon lock nut had been installed on the clevis bolt, and it was loose enough to be removed without the aid of any tools. The industry standard, found in FAA Advisory Circular AC43.13-1B, chapter 7, section 4, paragraph 7-64 states that nylon locking nuts should not be used with rotating components or assemblies. It further states that nylon and/or fiber nuts are highly susceptible to wear from repetitive use and from high heat applications.

Aircraft

Registration
N495WP
Reported as
WSK PZL Mielec M-18A
Category
Airplane
Serial number
1Z0206
Airframe hours
3,659
Engine
Pezetel ASZ621RM18, 985 horsepower, reciprocating
Damage
Substantial damage
Flight
Aerial application · Part 137
Operator
United States Forest Service
Registered owner
Western Pilot Service Inc.
Airworthiness certificate
Special, Restricted (Special)
Last inspection
100 hour · June 22, 2004 · 32 hours before
Departed
BNO · Burns, OR
Flight plan
Company VFR

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
59
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
January 10, 2004
Seat
Single
Flight hours
5,047 total · 2,373 in this make and model · 4,999 as pilot in command · 66 in the last 90 days · 33 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
0° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 37 °F
Altimeter
30.06 inHg
Observed at
BNO, 28 nm away