WPR22LA149

NTSB accident investigation · Dietrich Ryan S-4 Coyote 1 · Chula Vista, CA · April 8, 2022

Accident · No injuriesClass 3 · LimitedFinal report
Date
April 8, 2022, 15:30 local (22:30 UTC)
Place
Chula Vista, CA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N3156DDietrich Ryan S-4 Coyote 1
Defining event
Takeoff: Sys/Comp malf/fail (non-power)
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
20220408005199A
Case key
104926

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 pilot/owner and maintenance personnel’s improper installation of the right wing’s aft lift strut to the right wing, which resulted in a loss of lift during takeoff, an uncommanded right roll, and an impact with terrain.

Findings · 4

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.

Maintenance: installationPersonnel issues › Task performance · Owner/builderDietrich Ryan S-4 COYOTE 1: 1 caseAll aircraft: 371 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelDietrich Ryan S-4 COYOTE 1: 1 caseAll aircraft: 371 casesProbable cause
Maintenance/inspections: return to serviceAircraft › Aircraft handling/service · Incorrect service/maintenanceDietrich Ryan S-4 COYOTE 1: 1 caseAll aircraft: 14 casesProbable cause
Wing structure: fus (attach fitting on wing)Aircraft › Aircraft structures · Incorrect service/maintenanceDietrich Ryan S-4 COYOTE 1: 1 caseAll aircraft: 3 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 of the accident airplane was attempting to depart after his airplane had recently been returned to service following a hard landing about 9 months before that had collapsed the right main landing gear and damaged the wing strut. During the takeoff attempt on the day of the accident, when the pilot started to rotate, the airplane immediately entered an uncommanded right roll. The pilot’s attempts to counteract the roll were unsuccessful and the airplane impacted the ground. Postaccident examination of the airplane revealed that the right wing’s aft lift strut was not bolted to the right wing attachment clevis. As the left wing was intact and continued to produce lift, the unsecured right wing would have reduced the lift force acting on the right wing and, therefore, inhibited the pilot’s ability to maintain level flight. This condition is what likely resulted in an uncommanded right roll and impact with the ground. The airplane had recently been repaired by the pilot (who was also the owner) with assistance from his mechanic. During the rebuild, the mechanic placed a bolt upside down and with a finger-tight nylon locknut in the right wing’s aft lift strut to secure it to the right wing attachment clevis while they transported the airplane to a new hangar. The pilot and the mechanic never removed the bolt and the strut was never properly secured to the wing as required by the build manual before the accident flight. Both the pilot and mechanic performed the rebuild together and were both aware of the temporary measure used to secure the right wing’s aft lift strut to the right wing. The mechanic should have correctly completed the installation before he returned the airplane to service and the accident pilot should have recognized the absence of the hardware before he departed on the accident flight. Further, the pilot also missed the absence of the improper installation, having incorrectly assumed that the mechanic had performed a preflight inspection for him while they developed a preflight checklist.

Factual narrative

On April 8, 2022, about 1530 Pacific standard time, an experimental amateur-built Rans S4 Coyote 1, N3156D, was substantially damaged when it was involved in an accident near Chula Vista, California. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot, who was also the owner of the airplane, stated that the airplane suffered a hard landing about 9 months prior, which resulted in damage to the right wing, the wing strut, and right main landing gear. This was the pilot’s first flight in the accident airplane after it was repaired. According to the pilot, he completed a preflight inspection of the airplane with his mechanic and then started the airplane and taxied to runway 27. He aligned the airplane with the runway centerline and then gradually advanced the throttle for takeoff. When the airplane was about 300 ft into the takeoff roll he applied back pressure to the control stick and the airplane started to transition into a climb. However, the airplane immediately began a right roll when it was only a few feet above the ground. The pilot rapidly applied left control stick, but the airplane continued to roll to the right. He then pushed the control stick forward and applied left rudder to remain in ground effect and increase his airspeed, which slowed the right roll. The airplane was to the right of the right runway edge at an altitude of about 10 ft above ground level as it approached the departure end of the runway when the pilot decided he had insufficient control of the airplane to fly safely. At this point he reduced the engine power to idle and placed the airplane in a left crab, which allowed him to maintain a level attitude. As he pulled back on the flight stick to begin a landing flare, he felt the right wing drop again. The airplane touched down on the right main landing gear, which immediately collapsed, and the right wing impacted the ground. Inspection of the wreckage revealed that the right-wing’s aft strut was not bolted to its attachment clevis at the wing. Maintenance records indicated that the pilot performed the repair work on the airplane and signed it off on March 29, 2022, which involved replacing the right wing’s aft lift strut. According to the pilot’s mechanic, he assisted the pilot with the rebuild, and then completed an annual inspection at the end. After the inspection, the mechanic used a long 5/16” bolt with a finger-tight nylon locknut to secure the right wing’s lift strut to the right wing clevis while they moved the airplane to a new hangar. The pilot did not know what the mechanic used to pin the lift strut to the right wing but was aware of the temporary bolt. The airplane’s parts manual showed that the right wing’s aft lift strut is normally attached to the right wing clevis with one 5/16” bolt. The bolt is secured by a lockring. A logbook entry dated April 4, 2022, showed that the mechanic had performed an “annual conditioninspection” and certified that “the aircraft, engine, and propeller have been inspected in accordance with the scope and detail of FAR Part 43 subpart D and found to be in condition for safe operation.” According to FAR Part 43 Appendix D (referenced as “subpart” in the logbook endorsement), “(f) Each person performing an annual or 100-hour inspection shall inspect (where applicable) all components of the wing and center section assembly for poor general condition, fabric or skin deterioration, distortion, evidence of failure, and insecurity of attachment.” Figure 1: Right wing aft strut and attachment clevis The pilot’s mechanic reported that, just before the accident flight, he and the pilot decided to create a written preflight checklist for the airplane, which did not have one at the time. The mechanic walked around the airplane dictating items to include in the inspection while the pilot recorded the inspection items. The pilot stated that he thought the mechanic was performing a preflight inspection as he walked around the airplane; however, the mechanic maintained that he was not performing an inspection at that time.

Aircraft

Registration
N3156D
Reported as
Dietrich Ryan S-4 Coyote 1
Category
Airplane
Serial number
97251
Airframe hours
110
Engine
Hirth 3203, 65 hp, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Continuous airworthiness · April 8, 2022 · 3.7 hours before
Departed
0CL3 · Chula Vista, CA
Destination
Same as departure
Airport
0CL3 · John Nichols Field, runway 27, 1,700 × 35 ft, asphalt
Equipment
Handheld GPS, Electronic multifunction display

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
73
Injuries
None
Certificate
Sport Pilot
Airplane ratings
Single-engine land
Medical
Sport pilot, Without waivers/limitations
Last flight review
September 9, 2020
Seat
Single
Restraint
4-point
Flight hours
169 total · 18 in this make and model · 86 as pilot in command · 4 in the last 90 days · 1 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 12 knots, gusting 17
Visibility
10 statute miles
Lowest ceiling
None
Temperature
91 °F, dew point 23 °F
Altimeter
29.85 inHg
Observed at
KSDM, 6 nm away
METAR
KSDM 082253Z 29012G17KT 10SM CLR 33/M05 A2985 RMK AO2 SLP103 T03331050

Docket · 8

The files NTSB released with the investigation on March 28, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.2 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.