WPR13LA262

NTSB accident investigation · Piper PA-28-140 · Burlington, WA · June 4, 2013

Accident · No injuriesLimited investigationFinal report
Date
June 4, 2013, 09:30 local (16:30 UTC)
Place
Burlington, WA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N5808UPiper PA-28-140
Defining event
Landing-landing roll: Loss of control on ground
Weather
Visual (VMC) · Day
Status
Completed · report June 11, 2014
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
FAA FSDO
FAA report
20130604010099A
Case key
87089

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 failure of the rudder bar assembly during landing due to a fatigue crack. Contributing to the accident was the failure of maintenance personnel to perform an adequate inspection of the rudder bar assembly.

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.

Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelPiper PA-28-140: 9 casesAll aircraft: 320 casesProbable cause
Object/animal/substance: sign/markerEnvironmental issues › Physical environment · Contributed to outcomePiper PA-28-140: 8 casesAll aircraft: 214 cases

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 the landing roll, the airplane began to veer right, and the pilot applied left rudder and left braking action to align the airplane with the runway; however, both actions were ineffective. The airplane departed the right side of the runway and impacted an airport sign and a ditch. Postaccident examination of the left rudder bar assembly found that it had failed due to a fatigue crack. A rusted brown oxidized area near the center of the crack and surface features consistent with slow-growth fatigue indicated that the crack had been growing incrementally over a period of years. A review of the manufacturer's periodic inspection checklist, maintenance manual, and Service Letter No. 671 indicated that the rudder bar assembly should be inspected every 100 hours specifically for cracks in the area where the airplane's rudder bar failed. If maintenance personnel had inspected the airplane in accordance with these documents, the crack likely would have been found and the accident prevented.

Factual narrative

On June 4, 2013, at about 0930 Pacific daylight time, a Piper PA-28-140, N5808U, was substantially damaged when it struck an airport sign following a loss of directional control during landing roll at Skagit Regional Airport, Burlington, Washington. The private pilot, the sole occupant, was not injured. The pilot/owner was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the personal cross-country flight, which had originated from Friday Harbor, Washington, approximately 20 minutes before the accident. A flight plan had not been filed. The pilot said that while on landing roll, he applied left rudder to straighten the airplane, with no response. He said he attempted to correct the right veering tendency with left braking action, and that was ineffective as well. The airplane departed the right side of the runway and impacted an airport sign and a ditch, which damaged the right wing. Postexamination of the left rudder control bar found that it had failed. Examination of the rudder control bar at the NTSB Materials Laboratory found a fatigue crack, which originated from the edge of a weld. There was a rusted brown oxidized area near the middle of the crack, and the surface of this area had topography and crack patterns consistent with slow growth fatigue progressing from the exterior surface radially through the tube wall. The airplane was manufactured in 1970, and according to the owner, it had an airframe total time of 3,479 hours when the accident occurred. The most recent annual inspection was completed on May 25, 2013. A review of the Piper Aircraft's periodic inspection checklist, maintenance manual, and Service Letter No. 671 dated October 5, 1973, indicated that the rudder bar assembly should be inspected every 100 hours specifically for cracks in the area where the airplane's rudder bar failed. Further, the Service Letter stated that these periodic inspections could be discontinued if two reinforcement doublers were fabricated and welded to the rudder bar in the affected area. There were no reinforcement doublers on the airplane's rudder bar.

Aircraft

Registration
N5808U
Reported as
Piper PA-28-140
Category
Airplane
Serial number
28-26637
Built
1970
Airframe hours
3,479
Engine
Lycoming O-320 SERIES, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Morrissey William T Trustee
Registered owner
Morrissey William T Trustee
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 25, 2013
Departed
FHR · Friday Harbor, WA
Destination
BVS · Burlington, WA
Airport
BVS · Skagit Regional Airport, runway 11, 5,477 × 100 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
53
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
September 20, 2012
Seat
Left
Flight hours
4,023 total · 3,883 in this make and model · 4,023 as pilot in command · 25 in the last 90 days · 8 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
300° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 55 °F
Altimeter
30.15 inHg
Observed at
BVS

Docket · 7

The files NTSB released with the investigation on May 21, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.4 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.

Other investigations on N5808U · 1

Matched to the same aircraft by N-number and date.