WPR17LA164

NTSB accident investigation · Piper PA 28R-180 · San Jose, CA · July 23, 2017

Accident · No injuriesLimited investigationFinal report
Date
July 23, 2017, 12:47 local (19:47 UTC)
Place
San Jose, CA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N4594JPiper PA 28R-180
Defining event
Takeoff: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report January 25, 2018
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20170723011699A
Case key
95658

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

Maintenance personnel's incorrect installation of the aileron control cables and subsequent failure to verify proper aileron functionality following the maintenance, which resulted in roll control that was opposite of that commanded by the pilot, and the pilot's inadequate preflight inspection, during which he did not verify that the aileron movement matched the control yoke input.

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.

Flight control system: aileron control systemAircraft › Aircraft systems · Incorrect service/maintenancePiper PA-28R-180: 1 caseAll aircraft: 45 casesProbable cause
Flight control system: aileron control systemAircraft › Aircraft systems · Inadequate inspectionPiper PA-28R-180: 1 caseAll aircraft: 45 casesProbable cause
Inspection: post maintenance inspectionPersonnel issues › Task performance · PilotPiper PA-28R-180: 1 caseAll aircraft: 57 casesProbable cause
Inspection: post maintenance inspectionPersonnel issues › Task performance · Maintenance personnelPiper PA-28R-180: 1 caseAll aircraft: 57 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelPiper PA-28R-180: 2 casesAll aircraft: 371 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 commercial pilot reported that the accident flight was the first flight following maintenance, which included the installation of right-seat rudder pedals with brake controls. The pilot stated that, during a preflight inspection of the airplane, he actuated the ailerons; however, he did not verify which direction the control yoke moved. He again checked the flight control movement before takeoff but did not verify which direction the aileron moved when he moved the control yoke. During the takeoff sequence, as the airplane became airborne, it immediately entered an uncommanded left roll. The pilot attempted to correct for the roll; however, he was unable to do so and subsequently reduced the engine power. The airplane then impacted the ground and came to rest upright on an adjacent runway. Postaccident examination of the airplane revealed that, when the control yoke was rotated for input of right aileron, the right aileron moved down, and the left aileron moved up, which is opposite of what would be expected. Examination of the aileron cables revealed that they remained attached to the "T" bar aileron control chains; however, the right aileron control cable was attached to the left aileron control chain, and the left aileron control cable was attached to the right aileron control chain; thus, the cables were connected backward. The cables were oriented such that they crossed underneath the flap handle and center console area. The two mechanics who performed the maintenance on the airplane reported that they had disconnected the aileron control cables to facilitate the installation of the rudder pedals and brake controls. After completing the maintenance, they checked the flight control cable tension and aileron movement; however, they did not observe which direction the control yoke moved when the aileron was moved. It is likely that the mechanics attached the aileron control cables backward during the reassembly of the aileron control system, which resulted in roll control that was opposite of that commanded by the pilot.

Factual narrative

On July 23, 2017, about 1247 Pacific daylight time, a Piper PA-28R-180, N4594J, was substantially damaged during takeoff from the Reid-Hillview Airport (RHV), San Jose, California. The commercial pilot, sole occupant of the airplane, was not injured. The airplane was registered to Foluain Fabhcun LLC., Aptos, California, and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and no flight plan was filed for the cross-country flight, which was originating at the time of the accident with an intended destination of Marina, California. The pilot reported that the airplane had just had extensive maintenance performed, which included installation of several avionics upgrades, and right seat brake pedals; the accident flight was the first flight since the maintenance had been completed. During takeoff on runway 31R, as the airplane became airborne at an airspeed of about 80 miles per hour, it immediately entered an uncommanded roll to the left. The pilot said that he attempted to correct for the roll; however, he was unable to, and instead reduced engine power. Subsequently, the airplane impacted the ground and came to rest upright on runway 31L. Examination of the airplane by a Federal Aviation Administration inspector revealed that the fuselage and left wing were structurally damaged. Examination of the airplane by the National Transportation Safety Board investigator-in-charge revealed that when the control yoke was rotated for input of right aileron, the left aileron moved upward and the right aileron moved downward. Examination of the aileron cables revealed that they remained attached to the "T" bar aileron control chains. The right aileron control cable was attached to the left side aileron control chain and the left aileron control cable was attached to the right-side aileron control chain. The cables were oriented in a nature that they crossed underneath the flap handle and center console area. During a telephone conversation with one of the two mechanics that had worked on the airplane prior to the accident flight, he reported that he performed an oil change along with various other work while another mechanic was installing a second set of rudder pedals with brake controls on the right seat side of the airplane. In addition, the mechanic stated that he checked the airplane for flight control cable tension, noting that the operation was smooth, and visually looked at the ailerons while he was moving the control yoke. He added that at no time did he noticed that the aileron cables were installed backwards. The mechanic further reported that all work on the airplane was performed in accordance with the Piper Aircraft Maintenance Manual. The second mechanic reported that he disconnected aileron cables to facilitate installation of rudder pedals and brake assemblies, and subsequently reattached the aileron cables. The mechanic stated that he didnot observe the ailerons while the other mechanic checked aileron control deflections. During a telephone conversation with the pilot, he reported that prior to the flight, he performed a walk around inspection of the airplane and recalled that he moved the ailerons, but did not verify which direction the control yoke moved. In addition, he said that prior to takeoff, he checked the movement of all the flight controls, but did not verify which direction the ailerons moved when he moved the control yoke. The pilot stated that his primary focus was on the rudder and brakes as they were recently worked on.

Aircraft

Registration
N4594J
Reported as
Piper PA 28R-180 (180)
Category
Airplane
Serial number
28R-30470
Built
1968
Engine
Lycoming IO-320 SERIES, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Departed
RHV · San Jose, CA
Destination
Marina, CA
Airport
RHV · Reid-Hillview Of Santa Clara C, runway 31R, 3,100 × 75 ft, asphalt
Equipment
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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
70
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
May 31, 2016
Seat
Left
Restraint
3-point
Flight hours
6,000 total · 5,900 as pilot in command · 30 in the last 90 days · 15 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
91 °F, dew point 55 °F
Altimeter
29.82 inHg
Observed at
KRHV

Docket · 7

The files NTSB released with the investigation on November 3, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.8 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.