# NTSB WPR17LA087: Titan Tornado I, N5131H, Spanaway, WA, April 13, 2017 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: April 13, 2017, 09:40 local (16:40 UTC) - Place: Spanaway, WA - Coordinates: 47.081665, -122.428337 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=47.0817&lon=-122.4283&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report May 28, 2020 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 95012 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR17LA087 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95012/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95012 - Page: https://openairdocs.org/ntsb/WPR17LA087 ## Probable cause Maintenance personnel’s improper attachment of the aileron system components, which resulted in the pilot's inability to maintain flight control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Flight control system: aileron control system](https://openairdocs.org/ntsb-findings/01022710): Aircraft › Aircraft systems · Inadequate inspection (probable cause); cases with it: [Titan TORNADO I, 1 case](https://openairdocs.org/ntsb-findings/01022710/cases.md?model=05902VF), [All aircraft, 45 cases](https://openairdocs.org/ntsb-findings/01022710/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Titan TORNADO I, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=05902VF), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Titan TORNADO I, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=05902VF), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Takeoff: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) (defining event); cases with it: [Titan TORNADO I, 1 case](https://openairdocs.org/ntsb-events/333/sequence.md?model=05902VF), [All aircraft, 410 cases](https://openairdocs.org/ntsb-events/333/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Titan TORNADO I, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=05902VF), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The pilot reported that after departure for the personal flight, the airplane climbed to about 200 ft above ground level but he could not maintain level flight; he had to apply full right aileron and right rudder. The airplane rolled left, and he simultaneously reduced the engine power and applied forward elevator in an attempt to arrest the roll. Despite his attempts, the pilot could not regain control of the airplane and deployed the ballistic recovery system parachute (BRS). The airplane touched down hard off the airport, and the nose landing gear collapsed. As a result of the impact, the pilot was unable to egress under his own power; the engine continued to run, and the BRS drifted into the propeller. The engine continued to operate until the BRS suspension lines stopped the propeller. The examination of the aileron system revealed that the control tube was disconnected from the control mixer weldment. The stop nut that normally is affixed to the bolt connecting the aileron control tube to the control yoke tube was found on the cabin floor. The bolt end had a hole for a cotter pin, but no cotter pin was located. There were no markings on the nylon insert of the stop nut, which is consistent with the nut not being adequately attached during assembly. During the last condition inspection, about 4 months and 24 flight hours before the accident, an airframe and powerplant mechanic had adjusted the aileron control mixer. It is likely that during that maintenance activity, the nylon hardware was not properly attached to the aileron control tube. ## Factual narrative On April 13, 2017, about 0940 Pacific daylight time, an experimental Titan Tornado I airplane, N5131H, collided with terrain shortly after takeoff from Spanaway Airport, Spanaway, Washington. The commercial pilot was seriously injured. The airplane sustained substantial damage. The airplane was registered to and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed and no flight plan was filed for the flight which was originating at the time and was destined for Auburn, Washington. Witnesses stated that they observed the airplane climb out and turn. The ballistic recovery parachute (BRS) was activated while the airplane was at a low altitude. The accident site was located about 450 ft from the runway. The pilot stated that the purpose of his flight was to commute to his place of employment in Auburn. A normal preflight check was completed and the flight departed from runway 16. As the airplane climbed about 200 ft above ground level (agl), the pilot could not maintain level flight and he had to apply full right aileron and right rudder. The airplane rolled left and he simultaneously reduced the engine power and applied forward elevator in an attempt to arrest the roll. Despite his attempts, the airplane continued to roll left with the nose about 180° from the runway heading. Unable to regain directional control, the pilot decided to deploy the BRS. With an airspeed of about 80 mile per hour (MPH) and a level nose-pitch, the pilot pulled the activation handle. The pilot reported that after deploying the BRS, the left roll reduced to less than 5° of bank and he realized that he would not be able to return back to the runway. He concentrated his efforts on avoiding the trees and executed a forced landing in a field adjacent to the runway. He attempted to configure the airplane in a landing flare prior to touchdown by applying aft elevator. The airplane did not respond and touched down hard on the main landing gear, followed by the nose gear collapsing. As a result of the impact, the pilot's legs were injured and he was unable to egress under his own power. The engine continued to run and the BRS drifted into the propeller. The damage to the instrument panel made him unable to shut down the engine and it continued to operate until the BRS suspension lines stopped the propeller. The accident site was located on flat terrain about 435 ft east of the south end of the Spanaway Airport. The major sections of the airplane were all located within the immediate vicinity of the wreckage. The BRS, model number T2 300 (serial number T2B03690),was deployed with the parachute fabric draped on the terrain adjacent to the left wing. The fuel cap remained affixed to the intact fuel cell; the outside reference gauge indicated there was about 7.5-9 gallons of fuel on board. The airplane was configured in a pusher-type style, with the engine mounted above and aft of the cockpit. Thepropeller remained attached to the engine with all three blades intact. Approximately 3-4 ft of the BRS suspension lines were tightly wrapped around the propeller prohibiting crankshaft rotation. The activation handle inside the cockpit appeared to be in the "deployed position." There was a placard in the cockpit that read "Aircraft engine must be shut off prior to deploying parachute. Failure to do so may result in death or serious injury." The canopy, suspension lines, and slider remained intact and no damage was noted. Flight Controls During the post-accident examination, control continuity for the rudder and elevator systems was established. An examination of the aileron system revealed that there was control continuity from the aileron control surfaces to the control tube in the cockpit. The upper attach point of the control tube (near wings) remained intact and the lower end (in cockpit) was found disconnected from the control mixer weldment. The stop-nut that normally is affixed to the bolt connecting the aileron control tube to the control yoke tube was found on the cabin floor about 5 inches from the ball joint (see picture 1). The bolt end had a hole for a cotter pin, but no cotter pin was located. There was no markings on the nylon insert of the stop nut consistent with it not being adequately tightened during the last maintenance. The pilot reported that at the last condition inspection on 12/15/2016, the airframe and powerplant mechanic had adjusted the aileron control mixer. The airplane accumulated about 24 flight hours since the inspection. Picture 1: Aileron System ## Aircraft - Registration: [N5131H](https://openairdocs.org/aircraft/N5131H), registered now, S/N T95XXXCOHK0177 (OpenAirDocs) - Reported make and model: TITAN TORNADO I (NO SERIES) - Registry model: [Titan TORNADO I](https://openairdocs.org/model/titan-tornado-i) (registry code 05901KM) (OpenAirDocs) - Category: Airplane - Serial number: T95XXXCOHK0177 - Year built: 2006 - Airframe hours: 224 - Engines: Rotax 501 52 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, December 15, 2016, 24 hours before - Departed: S44, Spanaway, WA - Destination: S50, Auburn, WA - Airport: S44, Spanaway - Equipment: Airframe parachute ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; injuries: serious; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: helicopter, airplane; medical: class 2, without waivers/limitations; last flight review April 4, 2017; seat: front; flight hours: 1,409 total, 24 in this make and model, 1,224 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: 7,000 ft overcast - Temperature: 50 °F, dew point 46 °F - Altimeter: 29.77 inHg - Observed at: KTCM, 4 nm away ## 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 20170413002489A](https://openairdocs.org/incident/20170413002489A), Apr 13, 2017: Titan TORNADO I, Spanaway, WA, Substantial damage. On climbout flight control was lost. Brs chute was deployed and aircraft crashed just east of the runway. ## Docket (3 files) The files NTSB released with the investigation on January 16, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95012. 4.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479985&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Provided Witness Statements (item 2, .PDF, 184 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479986&FileExtension=.PDF&FileName=FAA%20Provided%20Witness%20Statements-Master.PDF - Examination Field Notes (item 3, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479987&FileExtension=.PDF&FileName=Examination%20Field%20Notes-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.