# NTSB WPR17LA102: Piper PA 18A, N245KW, Coeur D'Alene, ID, May 8, 2017 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: May 8, 2017, 13:30 local (20:30 UTC) - Place: Coeur D'Alene, ID - Coordinates: 47.774444, -116.819442 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=47.7744&lon=-116.8194&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: Minor injuries - Injuries: 1 minor - Status: Completed, report November 15, 2018 - Report: Approved by Office Director - NTSB office: Western Pacific Region - NTSB case key (mKey): 95133 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR17LA102 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95133/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95133 - Page: https://openairdocs.org/ntsb/WPR17LA102 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: yaw control](https://openairdocs.org/ntsb-findings/01062024): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-18A, 2 cases](https://openairdocs.org/ntsb-findings/01062024/cases.md?model=7101804), [All aircraft, 149 cases](https://openairdocs.org/ntsb-findings/01062024/cases.md) - [Maintenance/inspections](https://openairdocs.org/ntsb-findings/01010500): Aircraft › Aircraft handling/service · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-18A, 1 case](https://openairdocs.org/ntsb-findings/01010500/cases.md?model=7101804), [All aircraft, 103 cases](https://openairdocs.org/ntsb-findings/01010500/cases.md) - [Maintenance: replacement](https://openairdocs.org/ntsb-findings/02062020): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-18A, 1 case](https://openairdocs.org/ntsb-findings/02062020/cases.md?model=7101804), [All aircraft, 70 cases](https://openairdocs.org/ntsb-findings/02062020/cases.md) - [Flight control system: rudder control system](https://openairdocs.org/ntsb-findings/01022720): Aircraft › Aircraft systems · Failure (probable cause); cases with it: [Piper PA-18A, 1 case](https://openairdocs.org/ntsb-findings/01022720/cases.md?model=7101804), [All aircraft, 93 cases](https://openairdocs.org/ntsb-findings/01022720/cases.md) - [Record-keeping: aircraft/maintenance logs](https://openairdocs.org/ntsb-findings/02062515): Personnel issues › Task performance · Pilot; cases with it: [Piper PA-18A, 1 case](https://openairdocs.org/ntsb-findings/02062515/cases.md?model=7101804), [All aircraft, 21 cases](https://openairdocs.org/ntsb-findings/02062515/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) (defining event); cases with it: [Piper PA-18A, 1 case](https://openairdocs.org/ntsb-events/333/sequence.md?model=7101804), [All aircraft, 410 cases](https://openairdocs.org/ntsb-events/333/sequence.md) - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Piper PA-18A, 6 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7101804), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Landing-flare/touchdown: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Piper PA-18A, 5 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=7101804), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## 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](https://openairdocs.org/aircraft/N245KW), registered now, S/N 18-2495 (OpenAirDocs) - Reported make and model: Piper PA 18A (135) - Registry model: [Piper PA-18A](https://openairdocs.org/model/piper-pa-18a) (registry code 7101804) (OpenAirDocs) - Registry engine: [Lycoming 0-290 series](https://openairdocs.org/engine/lycoming-0-290-series) (registry code 41506, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 18-2495 - Year built: 1953 - Airframe hours: 4555 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: minor; 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 ## 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 20170508004799A](https://openairdocs.org/incident/20170508004799A), May 8, 2017: Piper PA-18A, Coeur D'Alene, ID, Substantial damage. Immediately after takeoff, at approximately 50 feet, the aircraft pitched forward and to the left and began rapidly descending. The left wingtip contacted the… ## Docket (4 files) The files NTSB released with the investigation on October 22, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95133. 20.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 6.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467616&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Witness Statements (item 2, .PDF, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467617&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Rudder Examination (item 3, .PDF, 8 photos, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467618&FileExtension=.PDF&FileName=Rudder%20Examination-Master.PDF - Wreckage and Log Book (item 4, .PDF, 1 photo, 9.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467619&FileExtension=.PDF&FileName=Wreckage%20and%20Log%20Book-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.