WPR19LA114

NTSB accident investigation · Great Lakes 2T-1A-2 · San Diego, CA · March 15, 2019

Accident · No injuriesClass 3 · LimitedFinal report
Date
March 14, 2019, 17:30 local (Mar 15, 2019, 00:30 UTC)
Place
San Diego, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N101GLGreat Lakes 2T-1A-2
Defining event
Enroute-climb to cruise: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20190314001459A
Case key
99276

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

The fracture of the aileron hinge strap due to fatigue crack propagation, which resulted in substantial damage to a wing rib aft of the spar at the outboard aileron cutout. Contributing to the accident was inadequate maintenance inspection.

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.

Flight control system: aileron control systemAircraft › Aircraft systems · Fatigue/wear/corrosionGreat Lakes 2T-1A-2: 1 caseAll aircraft: 45 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelGreat Lakes 2T-1A-2: 2 casesAll aircraft: 320 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

About 5 minutes after taking off, the pilot observed that the left upper aileron had come loose from the inboard hinge. The pilot returned to the departure airport and landed uneventfully. A postaccident examination of the airplane revealed that a wing rib aft of the spar at the outboard aileron cutout was substantially damaged. Examination of the aileron hinge strap fracture surfaces revealed crack arrest marks and thumbnail-shaped patterns on the fracture surfaces, which emanated from both the top and bottom surfaces of the hinge strap. The fracture surfaces were consistent with asymmetric reverse-bending fatigue crack propagation. The fatigue cracking propagated from the top and bottom surfaces through almost the entire cross-section of the hinge strap. The pilot reported that while there were no inspection criteria from the manufacturer relative to the hinge straps, all hinge straps were inspected as part of each annual inspection.

Factual narrative

On March 14, 2019, about 1730 Pacific daylight time, a Great Lakes 2T-1A-2 airplane, N101GL, sustained substantial damage when it was involved in an accident near San Diego, California. The private pilot and his passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. In a report submitted to the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), the pilot reported that, about 5 minutes after takeoff, the left upper aileron came loose from the inboard hinge and remained attached by the one remaining hinge. The pilot returned to the departure airport and landed uneventfully. Examination of the airplane revealed that a wing rib aft of the spar at the outboard aileron cutout was substantially damaged. The failed aileron hinge strap (two components) was secured by the NTSB IIC and sent to the NTSB Materials Laboratory for examination. The pilot mentioned that while there were no inspection criteria from the manufacturer relative to the hinge straps, all hinge straps were inspected as part of each annual inspection. Examination of the aileron hinge strap fracture surfaces by the NTSB Materials Laboratory technician revealed crack arrest marks and thumbnail-shaped patterns on the fracture surfaces emanating from both the top and bottom surfaces of the hinge strap. The thumbnail-shaped patterns are ratchet marks and their presence on both the top and bottom surfaces is consistent with asymmetric reverse-bending fatigue crack propagation. The fatigue cracking propagated from the top and bottom surfaces through almost the entire cross-section of the hinge strap.

Aircraft

Registration
N101GL
Reported as
Great Lakes 2T-1A-2
Category
Airplane
Serial number
0714
Built
1975
Airframe hours
2,412
Engine
Lycoming AEIO-360-B1G6, 180 hp, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Aerobatic; Standard, Normal
Last inspection
Annual · August 30, 2018 · 10 hours before
Departed
MYF · San Diego, CA
Airport
MYF · Montgomery-Gibbs Executive, runway 28R, 4,598 × 150 ft, asphalt
Equipment
Unknown

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
56
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Rear
Restraint
4-point
Flight hours
1,146 total · 155 in this make and model · 960 as pilot in command · 28 in the last 90 days · 8 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
64 °F, dew point 43 °F
Altimeter
29.92 inHg
Turbulence
Light
Observed at
MYF

Docket · 6

The files NTSB released with the investigation on November 2, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 19.7 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.

Other investigations on N101GL · 2

Matched to the same aircraft by N-number and date.