# NTSB WPR12LA261: Piper PA46R-350T, N488EA, Cameron Park, CA, June 5, 2012 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 4, 2012, 18:25 local (Jun 5, 2012, 01:25 UTC) - Place: Cameron Park, CA - Coordinates: 38.683612, -120.985832 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.6836&lon=-120.9858&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Landing gear collapse](https://openairdocs.org/ntsb-events/094) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report March 13, 2013 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Sacramento FSDO - NTSB case key (mKey): 83961 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR12LA261 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/83961/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=83961 - Page: https://openairdocs.org/ntsb/WPR12LA261 ## Probable cause The fatigue failure of the nose landing gear actuator attach foot during the landing roll. Contributing to the accident was the non-compliance with the manufacturer’s service bulletin. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Landing gear system: nose/tail gear attach section](https://openairdocs.org/ntsb-findings/01023221): Aircraft › Aircraft systems · Fatigue/wear/corrosion (probable cause); cases with it: [Piper PA46R-350T, 1 case](https://openairdocs.org/ntsb-findings/01023221/cases.md?model=7104610), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/01023221/cases.md) - [Landing gear system: nose/tail gear attach section](https://openairdocs.org/ntsb-findings/01023221): Aircraft › Aircraft systems · Failure (probable cause); cases with it: [Piper PA46R-350T, 1 case](https://openairdocs.org/ntsb-findings/01023221/cases.md?model=7104610), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/01023221/cases.md) - [Landing gear system: nose/tail gear attach section](https://openairdocs.org/ntsb-findings/01023221): Aircraft › Aircraft systems · Not inspected (probable cause); cases with it: [Piper PA46R-350T, 1 case](https://openairdocs.org/ntsb-findings/01023221/cases.md?model=7104610), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/01023221/cases.md) - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Not specified; cases with it: [Piper PA46R-350T, 1 case](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=7104610), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Landing gear collapse](https://openairdocs.org/ntsb-events/094) (defining event); cases with it: [Piper PA46R-350T, 2 cases](https://openairdocs.org/ntsb-events/094/sequence.md?model=7104610), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) ## Analysis During the landing roll after a normal touchdown, the nose landing gear collapsed, and the airplane departed the side of the runway. The investigation determined that the gear collapse was the result of the fatigue failure of the right side nose gear actuator attach foot, which then separated from the engine mount. Records showed that the accident airplane had been flown more than 300 hours since its most recent compliance with the Piper Aircraft service bulletin (SB) 1103D, which calls for the inspection of this specific area for cracks every 100 hours. Although Piper Aircraft Company considers its service bulletins to be mandatory actions, the Federal Aviation Administration does not require that service bulletins be complied with for aircraft that are used exclusively for 14 Code of Federal Regulations Part 91 operations, as this airplane was. Therefore, neither the owner of the airplane nor the maintenance personnel who performed annual inspections on the airplane were required to ensure compliance with SB 1103D. Failure to comply with SB 1103D could result in the nondetection of fatigue cracks that would eventually lead to the failure of a component of the engine mount/gear support assembly, as occurred in this accident. ## Factual narrative On June 4, 2012, about 1825 Pacific daylight time, a Piper PA46R-350T, N488EA, experienced a collapse of the nose landing gear at Cameron Airpark, Cameron Park, California. The private pilot, who was the sole occupant, was not injured, but the airplane, which was owned and operated by the pilot, sustained substantial damage. The 14 Code of Federal Regulations Part 91 personal flight, which departed Palo Alto Airport, Palo Alto, California, about 55 minutes prior to the accident, was being operated in visual meteorological conditions. No flight plan had been filed. According to the pilot, he made a normal uneventful landing, but during the landing roll the airplane's nose landing gear collapsed. After the collapse of the nose gear, the airplane temporarily departed the runway and encountered soft terrain, but the pilot was then able to bring it back onto the runway surface before it came to a stop. According to the Federal Aviation Inspector who responded to the scene, a part of the gear actuation and support system had separated from the location where it was attached to the engine mount, allowing the nose gear to partially retract, and resulting in a portion of the actuating system coming in contact with the firewall. The airplane was recovered to an on-field maintenance shop, where it underwent further examination. The examination of the airplane, which was under the direct supervision of a Federal Aviation Administration (FAA) Inspector assigned to the Sacramento Flight Standards District Office, revealed that the right side gear actuator attach foot had fractured and separated from the engine mount. The actuator then moved upward and aft, which allowed the nose landing gear to partially retract. As a result of the forces generated by the partial retraction of the nose landing gear, and the departure of the airplane from the runway, several engine mount braces were found either bent or broken. During this sequence of events, the engine firewall was substantially damaged. A field examination of the fractured metal tube revealed that a majority of the fracture face around its circumference showed a rough granular surface with a 45 degree fracture angle consistent with overload failure. A short section of the fracture, approximately 3/8 inch long, revealed the smoother shiny surface with beach marks and an area of pre-failure oxidation consistent with the propagation of a fatigue crack. A review of the airframe log book indicated that Piper Aircraft Service Bulletin 1103D (SB 1103D), issued on February 2, 2011, concerning the repetitive 100-hour inspection of the engine mount assembly for cracks, was complied with during an Annual Inspection performed on March 15, 2011. At the time of that inspection the airplane had accumulated 617.6 total hours. According to the inspection log entry no defects were found. The aircraft received its next Annual Inspection on March 9, 2012, and according to the log book, at that time the airplane had accumulated888.3 total hours. The log book entry from that Annual Inspection did not reference any compliance actions associated with SB 1103D, and there were no other subsequent entries referencing compliance with SB 1103D in the airplane’s log book. At the time of the accident, the airplane had accumulated 930 hours total time, and 313 hours since the last time SB 1103D was complied with. The investigation determined that although Piper Aircraft Company considers their Service Bulletins to be mandatory actions, the FAA does not require that they be complied with for aircraft that are used exclusively for FAR Part 91 operations, as this airplane was. Therefore, neither the owner of the airplane or the maintenance shops performing the annual inspections were required to make sure the actions called for by SB 1103D were complied with. However, failure to comply with SB 1103D could create the situation where fatigue cracks that would have been detected during SB 1103D compliance actions might go undetected, and eventually lead to the failure of a component of the engine mount/gear support assembly. ## Aircraft - Registration: [N488EA](https://openairdocs.org/aircraft/N488EA), registered now, S/N 4692016, built 2008 (OpenAirDocs) - Reported make and model: PIPER AIRCRAFT INC PA46R-350T - Registry model: [Piper PA46R-350T](https://openairdocs.org/model/piper-pa46r-350t) (registry code 7104610) (OpenAirDocs) - Registry engine: [Lycoming TIO-540-AE2A](https://openairdocs.org/engine/lycoming-tio-540-ae2a) (registry code 41999, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 4692016 - Airframe hours: 930 - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 9, 2012, 42 hours before - Departed: KPAO, Palo Alto, CA - Destination: 061, Cameron Park, CA - Flight plan: IFR - Airport: 061, Cameron Airpark, runway 13, 4,051 × 50 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 46; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review February 11, 2012; seat: left; flight hours: 1,953 total, 1,002 in this make and model, 1,872 as pilot in command, 48 in the last 90 days, 27 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 150° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 68 °F ## 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 20120604011519A](https://openairdocs.org/incident/20120604011519A), Jun 4, 2012: Piper Aircraft Inc PA46R-350T, Cameron Park, CA, Substantial damage. On June 4, 2012, at 1630 hours PDT, N488EA, a Piper PA-46R-350T, registered to fergieair LLC., had the nose landing gear collapse causing substaintial damage… ## Docket (6 files) The files NTSB released with the investigation on January 28, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=83961. 3.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385843&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Conversation - Piper Aircraft (item 2, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385845&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Piper%20Aircraft-Master.PDF - Record of Conversation - FAA Inspector (item 3, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385846&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20FAA%20Inspector-Master.PDF - Report from Piper Aircraft (9 Embedded Images) (item 4, .PDF, 9 photos, 395 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385847&FileExtension=.PDF&FileName=Report%20from%20Piper%20Aircraft%20(9%20Embedded%20Images)-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 5, .PDF, 335 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385848&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Photo 1. Fracture surface of the failed gear actuator attach rod, showing the portion displaying beach marks and facture surface oxidation. (item 6, .PDF, 900 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385849&FileExtension=.PDF&FileName=Photo%201.%20Fracture%20surface%20of%20the%20failed%20gear%20actuator%20attach%20rod,%20showing%20the%20portion%20displaying%20beach%20marks%20and%20facture%20surface%20oxidation.-Master.PDF 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.