# NTSB WPR13LA262: Piper PA-28-140, N5808U, Burlington, WA, June 4, 2013 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 4, 2013, 09:30 local (16:30 UTC) - Place: Burlington, WA - Coordinates: 48.474723, -122.42472 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=48.4747&lon=-122.4247&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report June 11, 2014 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA FSDO - NTSB case key (mKey): 87089 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR13LA262 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/87089/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=87089 - Page: https://openairdocs.org/ntsb/WPR13LA262 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Flight control system: rudder control system](https://openairdocs.org/ntsb-findings/01022720): Aircraft › Aircraft systems · Failure (probable cause); cases with it: [Piper PA-28-140, 2 cases](https://openairdocs.org/ntsb-findings/01022720/cases.md?model=7102802), [All aircraft, 93 cases](https://openairdocs.org/ntsb-findings/01022720/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28-140, 9 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=7102802), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Object/animal/substance: sign/marker](https://openairdocs.org/ntsb-findings/03022015): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-140, 8 cases](https://openairdocs.org/ntsb-findings/03022015/cases.md?model=7102802), [All aircraft, 214 cases](https://openairdocs.org/ntsb-findings/03022015/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: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Piper PA-28-140, 38 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7102802), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Piper PA-28-140, 47 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7102802), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## 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](https://openairdocs.org/deregistered/N5808U-2015-05-13), registration cancelled 2015-05-13, S/N 28-26637, built 1970 (OpenAirDocs) - Reported make and model: PIPER PA-28-140 - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-26637 - Year built: 1970 - Airframe hours: 3479 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; injuries: none; 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 ## 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 20130604010099A](https://openairdocs.org/incident/20130604010099A), Jun 4, 2013: Piper PA-28-140, Burlington, WA, Substantial damage. After touch down, aircraft veered to the right and went off runway. During the post-accident investigation conducted by FAA inspectors and members of the NTSB… ## Other investigations on N5808U (1) 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. - [NTSB LAX70FUM07](https://openairdocs.org/ntsb/LAX70FUM07), Mar 25, 1970: Piper PA-28 (N5808U), Julian, CA, substantial damage ## Docket (7 files) The files NTSB released with the investigation on May 21, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=87089. 3.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 637 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412497&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - NTSB Materials Laboratory Report (item 2, .PDF, 891 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412498&FileExtension=.PDF&FileName=NTSB%20Materials%20Laboratory%20Report-Master.PDF - Piper 100-Hour Inspection for Rudder Bar Assembly (item 3, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412500&FileExtension=.PDF&FileName=Piper%20100-Hour%20Inspection%20for%20Rudder%20Bar%20Assembly-Master.PDF - Piper Service Manual - Rudder Bar (item 4, .PDF, 187 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412501&FileExtension=.PDF&FileName=Piper%20Service%20Manual%20-%20Rudder%20Bar-Master.PDF - Piper 1973 Service Letter - Rudder Bar (item 5, .PDF, 183 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412502&FileExtension=.PDF&FileName=Piper%201973%20Service%20Letter%20-%20Rudder%20Bar-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 6, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412504&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Permission to Destroy Wreckage Part (item 7, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412505&FileExtension=.PDF&FileName=Permission%20to%20Destroy%20Wreckage%20Part-Redacted.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.