WPR17IA007

NTSB incident investigation · Short Bros SD3 60 Sherpa · Missoula, MT · October 13, 2016

Incident · No injuriesIncident investigationFinal report
Date
October 13, 2016, 16:45 local (22:45 UTC)
Place
Missoula, MT
Injuries
2 uninjured
Damage
Minor damage
Phase of flight
Approach
Aircraft
N148ZShort Bros SD3 60 Sherpa
Defining event
Approach: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed · report November 6, 2019
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
Case key
94210

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

On this page

Probable cause

The failure of the nose landing gear down-lock piston to engage due to paint accumulation, which resulted in a nose landing gear collapse during landing. Also causal was the failure of the facility that performed the painting to comply with manufacturer guidance regarding painting of the airplane.

Findings · 7

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.

Landing gear system: nose/tail gear strut/axleAircraft › Aircraft systems · Incorrect service/maintenanceShort Bros SD3-60 SHERPA: 1 caseAll aircraft: 36 casesProbable cause
Landing gear system: nose/tail gear strut/axleAircraft › Aircraft systems · Inadequate inspectionShort Bros SD3-60 SHERPA: 1 caseAll aircraft: 36 casesProbable cause
Oversight: oversight of maintenanceOrganizational issues › Support/oversight/monitoring · Maintenance providerShort Bros SD3-60 SHERPA: 1 caseAll aircraft: 28 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelShort Bros SD3-60 SHERPA: 1 caseAll aircraft: 320 casesProbable cause
Action: incorrect action performancePersonnel issues › Action/decision · Maintenance personnelShort Bros SD3-60 SHERPA: 1 caseAll aircraft: 1,386 casesProbable cause
Use of equip/info: use of available resourcesPersonnel issues › Task performance · Maintenance personnelShort Bros SD3-60 SHERPA: 1 caseAll aircraft: 41 casesProbable cause

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

The airline transport pilots reported that, during a ferry flight of an airplane that had just had been repainted, while on approach at its destination, the nose gear extended but failed to lock and subsequently collapsed on landing. Postaccident examination of the nose gear confirmed the nose gear's failure to lock, which led to its collapse. Observation of the nose gear down-lock actuator piston revealed that it had been painted, which prevented the piston from engaging and locking the nose gear during extension. Before the flight, maintenance personnel and the flight crew did not observe that the nose gear down-lock actuator piston area was painted. The airplane manufacturer issued a Service Information Letter (SIL) in 2007, that described a similar incident where the nose gear failed to lock in the down position on the first flight after an airplane had been repainted. The subsequent investigation revealed paint spray on the exposed piston of the nose landing gear down-lock actuator. The SIL stated "ensure that all masking material has been removed from the exposed piston after cleaning/painting, and that the piston is free from any paint or cleaning materials." Additionally, the landing gear emergency accumulator was observed during the preflight checks to be below the specified pressure. The accumulator was serviced to an adequate pressure prior to takeoff. Subsequently, the pressure bled down during the incident flight, and when the emergency landing gear extension was used by the flight crew, the accumulator did not have adequate pressure. According to the airplane manufacturer, the emergency landing gear extension is reliant on the main system pressure being depleted so that the emergency pressure can change a control valve position. Since the airplane's main hydraulic system was operative during the flight, the inability to use the landing gear emergency extension system, because of the lack of adequate pressure, would have been inconsequential, since the main system pressure was not depleted.

Factual narrative

On October 13, 2016, about 1645 mountain daylight time, a Short Bros SD3-60 Sherpa airplane, N148Z, sustained minor damage following a nose gear collapse during landing, at the Missoula International Airport (MSO) Missoula, Montana. The two airline transport pilots, were not injured. The airplane was registered to and operated by United States Department of Agriculture (USDA), as a public aircraft in support of the Forest Service. Visual meteorological conditions prevailed and a visual flight rules (VFR) flight plan was filed for the ferry flight which originated from Kingman Airport, Kingman, Arizona, about 1253. The pilots reported that prior to landing, they had an unsafe nose gear indication. After multiple unsuccessful attempts to get the nose gear to extend and indicate that it was down and locked, they decided to come in for a landing. During the landing roll, as the airplane's nose was lowered, the nose gear collapsed, and the forward section of the bottom of the fuselage, made contact with the runway surface. Once the airplane came to a stop, both pilots egressed. Examination of the airplane by the operator revealed minor damage on the underside of the fuselage. The airplane was returning to MSO, on its first flight, after being re-painted by a vendor in Kingman, Arizona. According to the operator, examination of the nose gear revealed that it failed to lock in the extended position and collapsed during landing. The flight crew attempted to extend and lock the nose gear during the flight but were unsuccessful. Post incident examination of the nose gear down-lock actuator piston (plunger), revealed that its chrome surface had been painted, which resulted in the locking piston not engaging, and prevented the locking of the nose gear during landing gear extension. The painting of the nose gear down-lock actuator piston was not observed by maintenance personnel or the flight crew on their pre-flight exterior checks. The airplane manufacturer Shorts issued a SD3-60 Sherpa Service Information Letter (SIL) Sherpa L-23, in April 2007, titled: Servicing/Painting – Removal of masking material/paint from nose landing gear down-lock actuator piston after cleaning/painting operations. The SIL described a similar incident where the nose gear failed to lock in the down position, on the first flight after the airplane had been re-painted. The subsequent investigation revealed paint spray on the exposed chrome piston of the nose landing gear down-lock actuator. The SIL stated "to ensure that all masking material has been removed from the exposed piston after cleaning/painting, and that the piston is free from any paint or cleaning materials." Additionally, the landing gear emergency accumulator was observed during the pre-flight checks to indicate below the specified pressure. The accumulator was serviced by maintenance to an adequate pressure, prior to takeoff. However, the pressure bled down during the incident flight, and when the emergency landinggear extension was used, the accumulator did not have adequate pressure. According to the operator's maintenance inspector, when activated, a fully serviced emergency accumulator forces the rapid application of hydraulic pressure into the system, however, according to the airplane's manufacturer, this is reliant on the main system hydraulic pressure being depleted so that the emergency pressure can change a control valve position. In this situation, the emergency pressure would be greater than the residual pressure of the failed main hydraulic system.

Aircraft

Registration
N148Z
Reported as
Short Bros SD3 60 Sherpa (SHERPA VAR)
Category
Airplane
Serial number
SH3428
Built
1994
Airframe hours
5,203.6
Engines
Pratt & Whitney PT6A-65R, 1,298 horsepower, turbo propPratt & Whitney PT6A-65R, 1,298 horsepower, turbo prop
Damage
Minor damage
Flight
Ferry · Public use
Operator
USDA Forest Service
Registered owner
USDA Forest Service
Airworthiness certificate
None
Last inspection
Condition · June 24, 2016
Departed
IGM · Kingman, AZ
Destination
MSO · Missoula, MT
Flight plan
VFR
Airport
MSO · Missoula Intl, runway 29, 9,501 × 150 ft, asphalt
Equipment
Angle of attack indicator, Auto-pilot, Data recorder

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
58
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, With waivers/limitations
Last flight review
March 6, 2015
Seat
Left
Restraint
4-point
Flight hours
8,715 total · 148 in this make and model · 7,755 as pilot in command · 82 in the last 90 days · 12 in the last 30 days · 8 in the last 24 hours
Role
Co-pilot
Age
49
Injuries
None
Certificates
Flight instructor, Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
March 2, 2016
Seat
Right
Restraint
4-point
Flight hours
6,424 total · 210 in this make and model · 4,921 as pilot in command · 90 in the last 90 days · 8 in the last 30 days · 8 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
360° at 6 knots
Visibility
10 statute miles
Lowest ceiling
7,000 ft overcast
Temperature
46 °F, dew point 34 °F
Altimeter
29.79 inHg
Observed at
MSO

Docket · 5

The files NTSB released with the investigation on July 5, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.8 MB in all.