# NTSB SEA06LA109: Piper PA-28-160, N1123W, Laurel, MT, June 2, 2006 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: June 2, 2006, 14:20 local (20:20 UTC) - Place: Laurel, MT - Coordinates: 45.710556, -108.749168 - Nearby events: https://openairdocs.org/map.md?lat=45.7106&lon=-108.7492&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report January 31, 2007 - Report: Approved by Office Director - Parties: Lycoming Textron, The New Piper Aircraft, Inc., Federal Aviation Administration - ADs cited in the narratives: [AD 69-22-02](https://openairdocs.org/ad/69-22-02) (OpenAirDocs) - NTSB case key (mKey): 63860 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA06LA109 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/63860/pdf - Page: https://openairdocs.org/ntsb/SEA06LA109 ## Probable cause The failure of maintenance personnel to properly reinstall the left-hand control yoke to the left-hand control column, and the failure of other maintenance personnel to properly verify the installation, which resulted in the pilot's loss of control in flight while maneuvering and subsequent impact with terrain. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, maneuvering - turn to reverse direction - maintenance,installation - improper, company maintenance personnel (cause) - maintenance,installation - not verified, other maintenance personnel (cause) - aircraft control - not possible, pilot in command (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis During the recent annual inspection the left-hand control yoke had been removed from the left-hand control column in compliance with a current FAA airworthiness directive; the control yoke was subsequently reinstalled to its respective control column. After taking off and beginning a left turn, the pilot experienced no aileron control input, impacting terrain in a nose low attitude. A post-accident examination revealed that the left-hand control yoke had not been properly reinstalled or verified that that installation was correct. ## Factual narrative On June 2, 2006, approximately 1420 mountain daylight time, a Piper PA-28-160 airplane, N1123W, sustained substantial damage after impacting terrain following a loss of control near Laurel, Montana. The airplane was registered to and operated by a private individual. The certificated private pilot, the airplane's sole occupant, sustained serious injuries. Visual meteorological conditions prevailed for the personal flight, which was operated in accordance with 14 CFR Part 91, and a flight plan was not filed. The local flight was originating at the time of the accident, with its destination being the Billings Logan International Airport (BIL), Billings, Montana. In telephone conversations with the NTSB investigator-in-charge (IIC), and according to the Pilot/Operator Aircraft Accident/Incident Report (NTSB Form 6120.1), the pilot reported that after picking the airplane up from a local maintenance facility following an annual inspection, he taxied to Runway 04, did his runup, and announced his intention to exit the pattern south for BIL. The pilot stated that shortly after taking off and commencing a turn to the left at approximately 300 feet above ground level (agl), he experienced no aileron control. The pilot stated that the last thing he remembered was cutting the power and observing two fields in front of him. The airplane subsequently impacted terrain about one-half mile north of the airport boundary and came to rest in an upright position. There was no post-crash fire. In statements submitted to the IIC, two pilot-rated witnesses reported observing the airplane in a nose high climb after taking off, then assume a bank attitude of about 30 degrees to the left between 300 and 500 feet agl. The witnesses stated that the airplane continued in a 180-degree turn, leveled off, then pitched down and impacted the ground at a near 30-degree angle. In a statement submitted to the IIC dated June 6, 2006, the Director of Maintenance (DO) for the facility which completed the airplane's annual inspection reported that during the inspection process the left-hand yoke was removed per a Federal Aviation Administration (FAA) Airworthiness Directive #69-22-02. The DO stated that after completing the inspection he had another mechanic reinstall the control yoke. The DO reported that he subsequently checked the installation and inserted the cotter pin into the [clevis] pin for the left-hand yoke, then installed the covers for both yokes. The DO revealed that he also checked the controls, however, he did not check the controls all the way to their stops. In a statement submitted to the IIC dated June 6, 2006, the mechanic who was delegated by the DO to reinstall the pilot's control yoke reported, "I slid the control yoke over the column and tried to put the pin in, but it would not go. Thinking that it must not be on far enough, I rotated it right and left while applying forward pressure. Using my right hand, I held the copilot's yoke and adjusted the pilot's yoke to line up parallel to it. Using a flashlight, I looked underneath to see if the holes were lined up. I saw a small piece of silver on one of the corners, so I knew I must be close, so I put the pin in and tested the controls. Both elevators worked as required with the elevator. I told the DO that it was in but still needed to be cotter pinned." In a follow-up telephone conversation with the IIC, the DO revealed that after the airplane had been recovered to his employer's facility, the same facility where the annual inspection had been performed, a subsequent examination by the DO and other company maintenance personnel revealed that the left-hand control yoke had not been attached and secured properly to the left-hand control column. This resulted in the control yoke moving freely around the control column, and therefore providing no input to either of the airplane's aileron controls. The DO subsequently notified an FAA aviation safety inspector of his findings. In a report submitted to the IIC, a Lycoming Textron engine representative reported no anomalies with the engine which would have precluded normal operation. The representative also reported that he observed the pilot control yoke separated from the shaft, with the clevis pin still in place on the yoke. He also observed a crack in the control column shaft's upper hole, and that the clevis pin was not engaged on the shaft. ## Aircraft - Registration: [N1123W](https://openairdocs.org/aircraft/N1123W), registered now, S/N 28-771 (OpenAirDocs) - Reported make and model: Piper PA-28-160 - Registry model: [Piper PA-28-160](https://openairdocs.org/model/piper-pa-28-160) (registry code 7102806) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-771 - Airframe hours: 3650 - Engines: Lycoming O-320-D2A 160 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Robert H. Wiens - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 1, 2006, 1 hours before - Departed: 6S8, Laurel, MT - Destination: BIL, Billings, MT - Airport: 6S8, Laurel Municipal Airport, runway 04, 5,200 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; seat: left; flight hours: 190 total, 75 in this make and model, 190 as pilot in command, 10 in the last 90 days, 5 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 90° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 88 °F, dew point 39 °F - Altimeter: 29.97 inHg - Observed at: BIL, 10 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 20060602008179A](https://openairdocs.org/incident/20060602008179A), Jun 2, 2006: Piper PA28160, Laurel, MT, Destroyed. (-23) This was the maiden flight after annual inspection - pilot states that on climb-out as he initiated a left turn the aileron control was ineffective. He… 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.