WPR17LA031

NTSB accident investigation · Piper PA 31T · Missoula, MT · December 5, 2016

Accident · No injuriesLimited investigationFinal report
Date
December 5, 2016, 13:00 local (20:00 UTC)
Place
Missoula, MT
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N909PWPiper PA 31T
Defining event
Enroute-cruise: Part(s) separation from AC
Weather
Instrument (IMC) · Day
Status
Completed · report November 6, 2018
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Helena FSDO
FAA report
20161205021579A
Case key
94465

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

Failure of the left windshield due to moisture ingression into the windshield laminate, which deteriorated the strength of the windshield.

Findings · 2

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.

Windows-windshield system: flight compartment windowsAircraft › Aircraft structures · Fatigue/wear/corrosionPiper PA-31T: 1 caseAll aircraft: 42 casesProbable cause
Windows-windshield system: flight compartment windowsAircraft › Aircraft structures · Damaged/degradedPiper PA-31T: 1 caseAll aircraft: 42 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 private pilot reported that, during cruise flight, the left windshield suddenly departed the airplane. The airplane was below its published service ceiling of 29,000 ft and the windshield was not subjected to internal pressure above its limitations at the time of the failure. The pilot entered an emergency descent and landed the airplane at an airport without further incident. The lack of windshield debris in the cockpit and the glass embedded in the left propeller indicated that the left windshield blew outward. Examination of the right windshield, which remained on the airplane, revealed evidence of moisture ingression into the laminate, to include cloudiness in the vinyl layer, interlayer cracking, delamination around the edges of the windshield, and corrosion of the aluminum retainer. Remnants of the left windshield were insufficient to establish if the laminate exhibited the same evidence of moisture ingression. Examination of the right windshield showed that the discrepancies were consistent with delamination as defined in the manufacturer's service manual. The discrepant areas had only progressed up to ½ inch into the daylight opening. The cloudiness, interlayer cracking, and delamination noted along the upper and lower edges of the right windshield were visible to the pilot before the accident flight. However, the delamination of the right windshield would not have necessitated immediate replacement based on the published service information, and although it is impossible to determine the condition of the left windshield before the flight, it was likely similar to that of the right windshield. The left windshield aluminum retainer exhibited corrosion around the periphery that was more extensive than that on the right windshield. The corrosion of the aluminum retainer is impossible to see with the windshields installed in the airplane, since the fuselage windshield frame covers the entire flange area. Windshields were designed in a manner to transfer their internal stresses equally around the windshield into the airframe structure. The corrosion of the aluminum retainer eliminated the load path for the internal windshield stresses to be transferred to the airframe. For each of the corroded areas on the aluminum retainer, there would have to be a redistribution of the internal stresses toward the intact areas, which would cause significant stress concentrations in the windshield laminate. These stress concentrations could be high enough to exceed the capabilities of the laminate in local areas. If coupled with a fracture of one glass layer, the stress concentration would be intensified even more adjacent to the corroded retainer areas. The corroded retainer on the left windshield led to areas of stress concentration within the windshield laminate. The precise initiation of the left windshield failure could not be conclusively determined. The little amount of glass remaining suggested that the fracture of the glass layers initiated inthe aft portion of the windshield near the center. It is possible there was a peel chip that began the event, or simply that the stress concentrations adjacent to the corroded retainer were high enough to cause failure of the windshield laminate.

Factual narrative

On December 5, 2016, about 1300 mountain standard time, a Piper PA-31T airplane, N909PW, made an emergency landing at Missoula International Airport (MSO), Missoula, Montana, following a fracture and separation of the left windshield from the airframe. The private pilot and passenger were not injured. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight originated from Kalispell City Airport (S27), Kalispell, Montana at 1215. The pilot reported that he was in cruise flight at flight level 230 for about 10 minutes, with an outside air temperature of - 40° Fahrenheit, when suddenly the left windshield departed the airplane. At the time of the windshield failure, the pilot heard an abrupt "swish" sound, followed by an instantaneous "loud roar" with a simultaneous blast of freezing air. The pilot and passenger donned their oxygen masks, and the pilot initiated an immediate descent. He made a distress radio call to air traffic control (ATC) declaring an emergency, and stated his intention to divert to Missoula, Montana; however, he was not able to hear a response from ATC due to the noise in the airplane. The pilot landed at MSO without further incident. The propeller driven, twin engine, low wing, pressurized airplane equipped with a retractable tricycle landing gear system, was manufactured in 1977. It was powered by two Pratt & Whitney Canada PT6 engines, each rated at 620 horsepower. The airplane was equipped with right and left electrically heated main windshields that were manufactured with two layers of glass. Data plates indicated that both windshields were manufactured by PPG Industries in Huntsville, Alabama. The left windshield was manufactured in January 1977 and the right windshield was manufactured in August 1981. A review of maintenance records indicated that the airplane was issued a standard airworthiness certificate on August 26, 1977 and mentioned that the airplane was exported. The next entry in the logbook was dated December 8, 1981, with the total time of 1712.12 hours. The airplane was ferried back to the United States and issued a Standard Airworthiness Certificate on December 17, 1981, with the total time of 1734 hours. There were no logbooks supplied for the period when the airplane was registered overseas. No information was found in the records to indicate when or why the right windshield was replaced. The most recent inspection of the airplane was accomplished on February 1, 2016, at a total time of 6267.5 hours with no discrepancies reported. The examination of the airplane revealed that most of the left windshield glass and vinyl departed the airframe during the event. The aluminum retainer and the vinyl beneath the fuselage windshield frame remained installed. Small areas of glass and vinyl were present around the edgeof the windshield frame. Only a few small glass fragments were found in the cockpit. The right windshield remained intact and installed in the airplane. There was no evidence of impact damage to the fuselage aft of the windshield or the tail of the airplane. There were small fragments of glass embedded in the left propeller blades. No evidence of bird impact was noted anywhere on the airplane. The fuselage windshield frame, sealant, and paint around both windshields were intact. The fractured remains of the left windshield and the intact right windshield were removed and subsequently examined at PPG Aerospace Transparencies, Huntsville, Alabama. The fractured left windshield aluminum retainer and flange area was intact. Several areas of retainer discoloration with a lighter color (white versus gray) were noted in the flange area on the inboard and outboard sides of the retainer. The largest discolored area was located along the lower flange and extended across the width of the retainer for about 6 inches on both the inboard and outboard sides of the retainer. The area was examined and a white powdery residue consistent with corrosion of the aluminum retainer was present, and the vinyl was no longer adhered to the aluminum. The right windshield was intact with no fracture of the inboard or outboard glass layers. Areas of retainer discoloration with a lighter color (white versus gray) were noted in the flange area on the inboard and outboard sides of the retainer though it was less severe than the left windshield. These areas were scattered around the periphery of the windshield with varying sizes and there was no large single area like noted on the left windshield. There was cloudiness, interlayer cracking, and delamination noted along the top and bottom edges of the windshield consistent with moisture ingression into the laminate. The discrepancies were noted along the entire upper edge and extended about 3/8 inch from the edge of the outboard glass layer towards the center of the windshield. The same discrepancies were also noted along the forward 13 inches of the lower edge and extended about 1/2 inch from the edge of the outboard glass layer towards the center of the windshield. Delamination was also noted at all four corners and along the bus bars at the lower forward and lower aft ends of the glass area. The Piper Cheyenne Service Manual provides guidance to operators for window inspection and repair. The manual defines three areas of the windshields: the critical area of the windshield defined as the viewing area used for taxiing, takeoff, climb, cruise and landing; the semi-critical area defined as the viewing area used for general flight vision and the non-critical areas defined as viewing areas normally not used for flight operations. Furthermore, the manual defines anomalies such as distortion, cracks, crazing, scratches, chips, haze, blemishes, mark-off, and delamination for use when inspecting the windshields. Cracks are consideredcritical for the glass windshields. Cracking of either the inboard or outboard glass layer is cause for immediate replacement. Delamination as evidenced by a cloudy or milky appearance is indicative of moisture or solvent penetration into the windshield laminate. Any delamination present in the critical and semi-critical areas should be replaced at the earliest opportunity. In addition, if the semi-critical section exhibits evidence of chipping of the inner glass surface, the windshield should be replaced.

Aircraft

Registration
N909PW
Reported as
Piper PA 31T (UNDESIGNAT)
Category
Airplane
Serial number
31T-7720060
Built
1977
Airframe hours
6,850
Engines
P&W PT6A SER, 620 horsepower, turbo propP&W PT6A SER, 620 horsepower, turbo prop
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 1, 2016
Departed
S27 · Kalispell, MT
Destination
LAS · Las Vegas, NV
Flight plan
IFR
Equipment
Auto-pilot, Stall warning system

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
43
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
April 1, 2016
Seat
Left
Restraint
3-point
Flight hours
2,235 total · 132 in this make and model · 2,104 as pilot in command · 26 in the last 90 days · 0 in the last 30 days · 0 in the last 24 hours
Role
Pilot-rated passenger
Age
39
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Seat
Right
Restraint
3-point
Flight hours
70 total · 30 as pilot in command · 0 in the last 90 days · 0 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
10° at 7 knots
Visibility
10 statute miles
Lowest ceiling
6,000 ft broken
Temperature
27 °F, dew point 10 °F
Altimeter
30.02 inHg
Observed at
KMSO, 5 nm away

Docket · 9

The files NTSB released with the investigation on July 5, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.7 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.