SEA96LA140

NTSB accident investigation · Piper PA-31 · Jackson, WY · July 2, 1996

Accident · No injuriesLimited investigationFinal report
Date
July 2, 1996, 07:30 local (13:30 UTC)
Place
Jackson, WY
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N27518Piper PA-31
Weather
Visual (VMC) · Day
Status
Completed · report August 25, 1997
Report
Approved by Office Director
FAA report
19960702019929A
Case key
42404

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

An improper screw installation by an unknown individual into the instrument panel, which restricted movement of the gear handle resulting in premature disengagement of the normal landing gear extension system. A factor was one or more improperly adjusted nose gear system components, which resulted in an unlocked nose gear that falsely indicated down and locked.

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.

Nose gear collapsedLanding - flare/touchdown
Maintenance,installation - improperUnknownCause
Landing gear,gear switch - movement restricted
Landing gear,normal retraction/extension assembly - disengaged
Maintenance,adjustment - improperUnknownFactor
Landing gear,nose gear - unlocked
Landing gear,gear indicating system - false indication

Analysis

During a normal landing, the aircraft's nose gear collapsed. The pilots stated that three green indicator lights were observed during the final landing checklist. In postaccident troubleshooting, an instrument panel mounting screw which was too long was discovered. This screw was obstructing the movement of the landing gear selector handle to a full down position, allowing it to return prematurely to neutral (which removes hydraulic pressure from the gear system.) The nose gear was thus not hydraulically moved over center and was unlocked, even though the nose gear indicated down and locked in this configuration. Per the aircraft service manual, the nose gear linkage incorporates a downlock spring, and both gear linkage overcenter travel and gear down limit switch position are adjustable. It was not determined whether, or when, these items were checked or adjusted before the accident. After the proper screw was installed in the instrument panel, the gear operated properly in retraction tests.

Factual narrative

On July 2, 1996, approximately 0730 mountain daylight time, a Piper PA-31, N27518, registered to Satellite Aero of Jackson, Wyoming and operating with the call sign of SXX1826, was substantially damaged when its nose landing gear collapsed during landing at Jackson Hole Airport in Jackson. Neither the airline transport pilot-in-command nor a pilot-rated passenger were injured. The flight operated under 14 CFR 135 as a United Parcel Service feeder cargo flight and had originated at Salt Lake City International Airport, Salt Lake City, Utah. Visual meteorological conditions prevailed and the flight was on a visual flight rules flight plan.

The pilot submitted a written statement to the NTSB investigator in which he stated that he observed three green lights during the final landing checklist. He also stated that at least two individuals on the ground, whom he named in his statement, observed the gear in the down position. The passenger, in a written statement, stated that the airplane was at 100 knots over the runway 36 threshold fence which he stated "is perfect for that airplane" and that the main gear touched down "just past the numbers." The pilot stated: "The final approach was a stabilized landing with the indicated airspeed approx[imately] 90 [knots] in the flare." Both occupants stated that at main gear touchdown, a warning horn sounded which they thought was the stall warning horn, and that the nose then contacted the runway and the airplane slid to a stop. Winds at the time of the event were reported as calm. The load manifest indicated that the airplane was loaded with 1,030 pounds of cargo and was within its maximum gross weight limit at the time of the accident.

In a letter to the FAA inspector assigned to the accident, dated February 22, 1997, Jackson Hole Aviation's director of maintenance reported on the findings of post-accident troubleshooting of the landing gear system. The director of maintenance reported that during post-accident troubleshooting, an instrument panel mount screw which was too long was discovered. The time at which the improper screw was installed was not determined. According to the director of maintenance, the improper screw obstructed the landing gear handle from moving to a full down position, permitting the gear handle to return to the neutral position with "very little hydraulic pressure" (the three-position gear selector switch is designed to return hydraulically to the center "neutral" or "off" position upon completion of gear extension or retraction). The director of maintenance stated that with the gear handle in neutral, the gear system would not pressurize and the nose gear drag brace was not hydraulically over-centered; the nose gear was thus not locked down. The director of maintenance reported that the nose gear position indicator on the accident aircraft displayed a green light with the landing gear in this configuration (however, the nose gear down limit switch position is adjustable, and should be adjusted to illuminate the green light with the nose gear in a proper down and locked position, according to the aircraft service manual). The director of maintenance reported to the FAA that after the improper screw was replaced with the proper part, a number of gear retraction tests were completed on the accident aircraft without any problems.

In examination of nose landing gear assembly diagrams in the PA-31 service manual, it was noted that the nose landing gear assembly design incorporates a downlock spring which exerts tension on the linkage to move it in a down-and-locked direction. The PA-31 service manual also contains checking and adjustment procedures to ensure proper overcenter travel of the nose gear linkage. It was not determined whether these procedures had been performed on the accident aircraft at any time prior to the accident. However, 14 CFR 43, Appendix D, requires landing gear system linkages, trusses, and members to be inspected for undue or excessive wear, fatigue, and distortion, and that gear retracting and locking mechanisms be checked for improper operation, on annual and 100-hour inspections. According to copies of the aircraft logs supplied by the operator, the aircraft received an annual/100-hour inspection on May 4, 1996. The operator reported that the aircraft had flown 93.1 hours since the last inspection.

Aircraft

Registration
N27518
Reported as
Piper PA-31
Category
Airplane
Serial number
31-7812038
Airframe hours
7,726
Engine
Lycoming TIO-540-2AC, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Registered owner
Satellite Aero Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · May 4, 1996 · 94 hours before
Departed
SLC · Salt Lake City, UT
Destination
JAC
Flight plan
VFR
Airport
JAC · Jackson Hole, runway 36, 6,299 × 150 ft, asphalt

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
47
Certificates
Airline transport, Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
4,020 total · 600 in this make and model · 3,724 as pilot in command · 75 in the last 90 days · 25 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
46 °F, dew point 39 °F
Altimeter
30.00 inHg
Observed at
JAC

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.