# NTSB WPR23LA216: Cessna 172R, N819KS, Santa Monica, CA, June 5, 2023 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: June 5, 2023, 15:17 local (22:17 UTC) - Place: Santa Monica, CA - Coordinates: 34.015822, -118.4513 - Nearby events: https://openairdocs.org/map.md?lat=34.0158&lon=-118.4513&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration, Textron Aviation - NTSB case key (mKey): 192319 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR23LA216 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192319/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=192319 - Page: https://openairdocs.org/ntsb/WPR23LA216 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Landing gear system: nose/tail gear attach section](https://openairdocs.org/ntsb-findings/01023221): Aircraft › Aircraft systems · Failure (probable cause); cases with it: [Cessna 172R, 1 case](https://openairdocs.org/ntsb-findings/01023221/cases.md?model=2072401), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/01023221/cases.md) - [Landing gear system: nose/tail gear attach section](https://openairdocs.org/ntsb-findings/01023221): Aircraft › Aircraft systems · Inadequate inspection (probable cause); cases with it: [Cessna 172R, 1 case](https://openairdocs.org/ntsb-findings/01023221/cases.md?model=2072401), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/01023221/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Cessna 172R, 37 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=2072401), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Maintenance: replacement](https://openairdocs.org/ntsb-findings/02062020): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 172R, 1 case](https://openairdocs.org/ntsb-findings/02062020/cases.md?model=2072401), [All aircraft, 70 cases](https://openairdocs.org/ntsb-findings/02062020/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 172R, 2 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=2072401), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Cessna 172R, 3 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=2072401), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Landing-landing roll: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) (defining event); cases with it: [Cessna 172R, 1 case](https://openairdocs.org/ntsb-events/330/sequence.md?model=2072401), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Cessna 172R, 40 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2072401), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) ## 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](https://openairdocs.org/aircraft/N819KS), registered now, S/N 17280914, built 2000 (OpenAirDocs) - Reported make and model: CESSNA 172R - Registry model: [Cessna 172R](https://openairdocs.org/model/cessna-172r) (registry code 2072401) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17280914 - Year built: 2000 - Airframe hours: 8756.3 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 36; injuries: none; 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= ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20230605015709A](https://openairdocs.org/incident/20230605015709A), Jun 5, 2023: Cessna 172R, Santa Monica, CA, Substantial damage. On June 5, 2023, about 1517 pacific daylight time, a Cessna 172R, [privacy data omitted], was substantially Damaged when it was involved in an accident near… ## Docket (10 files) The files NTSB released with the investigation on June 20, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=192319. 71.2 MB in all. - NTSB materials laboratory factual report (item 1, PDF, 12 pages, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16337551&FileExtension=pdf&FileName=23-091%20Materials%20Laboratory%20Factual%20Report-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 2, PDF, 11 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16338225&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Record of conversations (item 3, PDF, 3 pages, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16529164&FileExtension=pdf&FileName=record%20of%20conversations-Rel.pdf - Video of damage from pickup truck collision (item 4, MP4, 58.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16496621&FileExtension=mp4&FileName=N819KS%20Damage%20Summary-Rel.mp4 - Airport surveillance footage of touchdown and accident (item 5, MP4, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16337945&FileExtension=mp4&FileName=6-5-2023%20incident_3_01-Rel.mp4 - Nose landing gear excerpt from maintenance manual (item 6, PDF, 11 pages, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16496391&FileExtension=pdf&FileName=MM%20NLG-Rel.pdf - Nose landing gear ipc excerpt (item 7, PDF, 5 pages, 561 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16495954&FileExtension=pdf&FileName=NLG%20IPC%20excerpt-Rel.pdf - Maintenance work order (item 8, PDF, 1 page, 560 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16338289&FileExtension=pdf&FileName=Bills%20Air%20Center%20Bill_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 9, PDF, 1 page, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16337935&FileExtension=pdf&FileName=Release%20of%20Wreckage_Redacted-Rel.pdf - Accident photographs (item 10, PDF, 4 pages, 772 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16496589&FileExtension=pdf&FileName=Accident%20Photographs-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.