WPR17LA102

NTSB accident investigation · Piper PA 18A · Coeur D'Alene, ID · May 8, 2017

Accident · Minor injuriesLimited investigationFinal report
Date
May 8, 2017, 13:30 local (20:30 UTC)
Place
Coeur D'Alene, ID
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N245KWPiper PA 18A
Defining event
Takeoff: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report November 15, 2018
Report
Approved by Office Director
NTSB office
Western Pacific Region
FAA report
20170508004799A
Case key
95133

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

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Probable cause

The loss of yaw control due to an inadequately compressed rudder swage, which resulted from inadequate maintenance and led to the separation of the forward right rudder cable.

Findings · 5

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.

Performance/control parameters: yaw controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-18A: 2 casesAll aircraft: 149 casesProbable cause
Maintenance/inspectionsAircraft › Aircraft handling/service · Incorrect service/maintenancePiper PA-18A: 1 caseAll aircraft: 103 casesProbable cause
Maintenance: replacementPersonnel issues › Task performance · Maintenance personnelPiper PA-18A: 1 caseAll aircraft: 70 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, shortly after takeoff for the personal flight, the airplane began to yaw left and that he applied right rudder input in an attempt to regain yaw control; however, the airplane did not respond. The pilot subsequently initiated a forced landing, during which the airplane impacted the ground in a nose-down attitude, and it then came to rest oriented about 90o perpendicular to the runway. Postaccident examination revealed that the forward right rudder cable, between the front and rear seats, had detached at the rear seat foot pedal connection. The cable had pulled through its swage sleeve, indicating that the swage had not been adequately compressed. The cable appeared to have been recently replaced; however, during a review of maintenance records, no logbook entry was found documenting the replacement.

Factual narrative

On May 8, 2017, about 1330 Pacific daylight time, a Piper PA18A airplane, N245KW, sustained substantial damage when it impacted terrain shortly after takeoff from Coeur d'Alene Airport (COE), Coeur d'Alene, Idaho. The private pilot sustained minor injuries. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed, and no flight plan had been filed for the local flight. The purpose of the flight was to practice maneuvers in the local area. The pilot, who was seated in the front seat, reported that during takeoff he applied one notch of flaps to assist with a shorter takeoff roll. During the initial climb, the airplane yawed to the left and he applied the right rudder; however, the airplane did not respond. About 50 to 75 ft above ground level, the pilot retarded the throttle, and initiated a forced landing. The airplane impacted the ground in a nose down attitude and came to rest oriented about 90° perpendicular to the runway. On July 20, 2017, the airplane was examined at a secure facility by an NTSB Investigator accompanied by a Federal Aviation Administration Inspector. The right rudder pedal was found full forward against the firewall and trapped behind the cabin's front "V" brace. The right rudder cable, between the front and rear seat, had detached at the rear seat foot pedal connection. The thimble remained attached to the rear seat pedal assembly, and the free end of the cable was found loosely threaded through its swage sleeve. The failed rudder cable and swage sleeve appeared bright and clean when compared to the remaining rudder cables in the system, consistent with its recent replacement. There was no annotation in the maintenance logbooks indicating the cable had been replaced. Right rudder cable from rudder intact. Cable thimble to front seat attached, cable missing

Aircraft

Registration
N245KW
Reported as
Piper PA 18A (135)
Category
Airplane
Serial number
18-2495
Built
1953
Airframe hours
4,555
Engine
Lycoming O320-A2B, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 23, 2016
Departed
COE · Coeur D'Alene, ID
Destination
COE · Coeur D'Alene, ID
Airport
COE · Coeur D'Alene - Pappy Boyingto, runway 20, 5,400 × 75 ft, asphalt
Equipment
Handheld GPS

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
61
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
June 25, 2016
Seat
Front
Restraint
Lap only
Flight hours
654 total · 145 in this make and model · 584 as pilot in command · 12 in the last 90 days · 7 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
57 °F, dew point 30 °F
Altimeter
30.17 inHg
Observed at
KCOE

Docket · 4

The files NTSB released with the investigation on October 22, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 20.2 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.