WPR23LA216

NTSB accident investigation · Cessna 172R · Santa Monica, CA · June 5, 2023

Accident · No injuriesClass 3 · LimitedFinal report
Date
June 5, 2023, 15:17 local (22:17 UTC)
Place
Santa Monica, CA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N819KSCessna 172R
Defining event
Landing-landing roll: 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, Textron Aviation
FAA report
20230605015709A
Case key
192319

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

A failure of the nose wheel upper torque link bolt, which resulted in a loss of steering control. Contributing to the accident were maintenance personnel’s failure to inspect and replace the fractured bolt and the pilot’s oversight of the bolt during his preflight inspection.

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.

Landing gear system: nose/tail gear attach sectionAircraft › Aircraft systems · Inadequate inspectionCessna 172R: 1 caseAll aircraft: 29 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleCessna 172R: 37 casesAll aircraft: 3,958 casesProbable cause
Maintenance: replacementPersonnel issues › Task performance · Maintenance personnelCessna 172R: 1 caseAll aircraft: 70 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotCessna 172R: 2 casesAll aircraft: 551 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 was completing a maintenance flight to determine that the airplane was airworthy after repairs following a collision with a fuel truck that had taken place one month before the accident. The high-speed taxi test and subsequent flight in the airport traffic pattern were uneventful. However, when the pilot landed the airplane, the nosewheel began a shimmy that intensified as the airplane slowed. The airplane began to veer left, and the pilot attempted to correct the movement with right rudder, aerodynamic braking, and then both brakes, but the airplane nosed over and came to rest inverted, which resulted in substantial damage to the rudder. A bolt from the upper portion of the nose torque link was found on the runway and a poastaccident material analysis revealed that the bolt had separated from shear overstress. The investigation also found that the bolt had been damaged and was not replaced as part of the repairs made to prepare the airplane for the ferry flight following the previous collision with the fuel truck. The accident was the result of a failure of the upper torque link during landing. The link failed due to a bolt that had unaddressed fractures originating from when the airplane collided with the truck. This resulted in a loss of steering control and a subsequent loss of directional control on the ground. A video provided by the airplane owner of the airplane showing the damage on the airplane following the collision with the fuel truck clearly shows the bent upper torque link bolt.

Factual narrative

On June 5, 2023, about 1517 Pacific daylight time, a Cessna 172R, N819KS, was substantially damaged when it was involved in an accident near Santa Monica, California. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 test flight. The pilot stated that he was performing a maintenance test flight (the airplane’s first flight) following a repair for a collision with a fuel truck that occurred about one month earlier. On the day of the accident, he inspected the nose landing gear assembly and “saw nothing out of sorts” that would have caused him to cancel the flight. After a high-speed taxi he determined that the airplane was safe to fly in the airport traffic pattern. The pilot departed runway 21, remained within the airport traffic pattern, and touched down normally on the departure runway. During landing roll, as the nose landing gear contacted the runway, it began to shimmy. The pilot applied back pressure to the control yoke to keep the airplane’s weight off the nosewheel; however, once the airplane slowed the nose wheel shimmy intensified. Subsequently, the pilot heard a sound that resembled a piece of metal strike the lower engine cowling. The airplane veered left despite the pilot’s attempts to correct the movement with right rudder. His attempt to apply the brakes also exacerbated the turn and he continued to use aerodynamic braking with back pressure on the control yoke. The airplane then veered left aggressively and, when the pilot attempted to reapply the brakes, the right wing dipped and collided with the ground. The airplane nosed over and came to rest inverted, which resulted in substantial damage to the rudder. A bolt from the nose wheel torque link assembly was found on the runway during a sweep for foreign object debris following the accident. In addition, the torque link had separated from the nose wheel steering arm assembly at the upper bolt (see Figure 1). According to the airplane maintenance manual, “The torque links give a mechanical link between the top and bottom parts of the shock strut and help keep the nosewheel aligned with the airframe.” The illustrated parts catalogue shows that the upper torque link connects to the nose gear steering arm assembly and the lower torque link connects to the nose wheel fork. Figure 1: Nose wheel torque link and bolt from accident Bolt Examination A National Transportation Safety Board Materials Laboratory examination found that both the upper and lower torque link bolt measurements and thread profiles were consistent with the proper bolt for the installation. The bolthead had separated from the bolt shank, but the corresponding castellated nut and cotter pin were secure in place. The fracture surface had directional dimples consistent with shear overstress. Prior Damage In May 2023 the airplane collided with a fuel truck as it was being towed by the operator. The airplane owner videotaped the damage to the airplane, which showed abent tow point and a curved bolt with a castellated nut protruding from the upper torque link to nose gear steering arm assembly connection. According to an invoice, the damage was inspected and 10 shock mounts on the cowling were replaced to prepare the airplane for a ferry flight as the damage, including the strut, was going to be repaired by another maintenance facility. The operator stated that the instructor was then asked to complete the maintenance flight (accident flight) after the airplane was serviced to ensure it was airworthy before the ferry flight. Figure 2: Damage to nose gear after collision with truck (May 2023)

Aircraft

Registration
N819KS
Reported as
Cessna 172R
Category
Airplane
Serial number
17280914
Built
2000
Airframe hours
8,756.3
Engine
Lycoming IO-360-L2A, 180 hp, reciprocating
Damage
Substantial damage
Flight
Flight test · Part 91
Registered owner
Planelease LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 30, 2023 · 47.8 hours before
Departed
SMO · Santa Monica, CA
Destination
Same as departure
Airport
SMO · Santa Monica Muni, runway 21, 3,500 × 150 ft, asphalt
Equipment
Stall warning system, ADS-B

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
36
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
April 28, 2022
Seat
Left
Flight hours
730.9 total · 591.5 in this make and model · 574.5 as pilot in command · 132.4 in the last 90 days · 30.7 in the last 30 days · 1.7 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 4 knots
Visibility
10 statute miles
Lowest ceiling
3,100 ft overcast
Temperature
63 °F, dew point 50 °F
Altimeter
29.91 inHg
Observed at
KSMO
METAR
SPECI KSMO 052218Z VRB04KT 10SM OVC037 17/10 A2991 RMK AO2 T01670100=

Docket · 10

The files NTSB released with the investigation on June 20, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 71.2 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.