WPR21LA135

NTSB accident investigation · Aviat A-1C-200 · Carefree, AZ · February 19, 2021

Accident · No injuriesClass 3 · LimitedFinal report
Date
February 18, 2021, 17:30 local (Feb 19, 2021, 00:30 UTC)
Place
Carefree, AZ
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N43LLAviat A-1C-200
Defining event
Landing-landing roll: Loss of control on ground
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
FAA, Aviat Aircraft Inc.
FAA report
20210218000759A
Case key
102778

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 substandard installation of the airplane’s autopilot system hardware, which resulted in a malfunction of the rudder control system during flight and a loss of directional control during the landing roll.

Findings · 3

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.

Misc hardwareAircraft › Fluids/misc hardware · Incorrect service/maintenanceAviat A-1C-200: 1 caseAll aircraft: 41 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleAviat A-1C-200: 9 casesAll aircraft: 3,958 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 pilot reported that, during the approach to land, he disconnected the autopilot, and the airplane immediately yawed to the right. The pilot applied left pedal, engaged the yaw damper, and continued the approach. He subsequently disengaged the yaw damper and entered a cross-control slip to descend, and he was unable to make an effective left rudder input. The airplane touched down on the gravel runway surface and veered to the right. The airplane then crossed over to the asphalt runway surface and subsequently ground-looped. The airplane’s autopilot had been installed in the airplane 7 weeks before the accident. Postaccident examination of the airframe revealed that the autopilot hardware installation was substandard. Specifically, the guard pin, which was designed to prevent the bridle cable from traveling out of the pulley’s groove past the sheaves, was not installed to the yaw servo tray and the right pulley assembly, which allowed the yaw servo bridle cable to separate from the pulley’s phenolic sheave. Additionally, the bridle cable, which was undertensioned, became trapped between the yaw servo pulley and the attachment tray and prohibited the pilot from applying left rudder. As a result, the pilot was unable to maintain directional control during the landing roll. The guard pin is designed to prohibit the bridle cable from being able to travel out of the pulley’s groove past the sheaves.

Factual narrative

On February 18, 2021, about 1730 mountain standard time, an Aviat Aircraft A-1C-200, N43LL, sustained substantial damage when it was involved in an accident in Carefree, Arizona. The commercial pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, after an uneventful 2.9-hour cross-country flight, he configured the airplane for the approach to runway 24 at the destination airport. While descending the airplane, the pilot encountered a “rudder abnormality.” Specifically, the pilot stated that, when he disengaged the autopilot by depressing the red disconnect button on the control stick, the nose of the airplane immediately yawed to the right. To counteract the yawing motion, the pilot applied left rudder, and the airplane responded normally. The pilot then engaged the yaw damper, and rudder control remained normal. During final approach, the pilot disengaged the yaw damper at an altitude of about 800 ft above ground level and maneuvered into a cross-control left slip configuration. He subsequently applied left rudder to align the nose of the airplane with the runway, but the left rudder pedal was not effective, even when it was pressed to the floor. The pilot elected to land in a nose-right crab position. The airplane touched down on the gravel runway surface, veered to the right quickly, and crossed over the asphalt runway surface. The airplane’s left main landing gear collapsed, and its left wing contacted the ground. The airplane came to rest between the runway and the taxiway with the nose of the airplane oriented 180° opposite the intended landing direction. The pilot stated that the airplane had made a “classic ground loop.” A postaccident photograph of the airplane revealed that the left aileron sustained substantial damage. Review of the airframe logbook revealed that the autopilot system had been installed and returned to service on December 31, 2020, with a Hobbs time of 156.1 hours. At the time of the accident, the airplane had accumulated 15.7 hours since the autopilot installation. Postaccident examination of the airplane revealed that the yaw servo bridle cable exhibited no tension and had dislodged from the right pulley assembly attached to the servo tray. The bridle cable was routed under the pulley’s laminated phenolic sheave and was trapped between the yaw servo pulley and the attachment tray. Additionally, the postaccident photographs revealed that a guard pin designed to secure the bridle cable to the phenolic sheave was not present and the attachment tray’s upper and lower surface bore exhibited no evidence indicating that the guard pin had been installed. (The guard pin is designed to prevent the bridle cable from traveling out of the pulley’s groove past the sheaves.) Further examination of the autopilot hardware revealed the following installation deficiencies: o No cotter keys installed on yaw bridle cable to rudderblocks. o Torque on bridle cable clamps nuts unable to be measured with torque wrench because of low torque. Torque estimated to be between 5 and 10 inch pounds. o Gap on both bridle cable clamps measured as 0.026 inches. o Cable tension on bridle cable for yaw servo was 0 pounds. o No torque seal observed on bridle cable clamp at intersection of cable. o Cable tensions on yaw and roll servos was 0 pounds. o Cable tension on pitch servo was 7 pounds. o Torque on yaw and pitch servo guard pins measured to be 0 inch pounds. o Cotter pin missing from castellated nut securing roll pulleys with Part Nos. 115 03343-00 and 115-03344-00. o Cotter key missing from yaw servo pulley.

Aircraft

Registration
N43LL
Reported as
Aviat A-1C-200
Category
Airplane
Serial number
3313
Built
2018
Airframe hours
135.5
Engine
Lycoming IO-360-A106, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Glasair III Investors LLC
Registered owner
Glasair III Investors LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 6, 2020 · 36 hours before
Departed
AEG · Albuquerque, NM
Destination
Same as departure
Airport
18AZ · Sky Ranch at Carefree, runway 24, 4,029 × 50 ft, dirt
Equipment
Stall warning system, ADS-B, Angle of attack indicator, Auto-pilot, Electronic multifunction display, Onboard weather, Satellite tracking device

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
72
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2
Last flight review
March 6, 2021
Seat
Front
Restraint
5-point
Flight hours
7,543 total · 368 in this make and model · 7,489 as pilot in command · 47 in the last 90 days · 24 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
10° at 4 knots
Visibility
10 statute miles
Temperature
45 °F, dew point 12 °F
Altimeter
3014.00 inHg
Observed at
SDL, 12 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.