WPR23LA317

NTSB accident investigation · Piper PA-24-260 · Fullerton, CA · August 8, 2023

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
August 8, 2023, 15:00 local (22:00 UTC)
Place
Fullerton, CA
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N503JAPiper PA-24-260
Defining event
Enroute-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 FSDO
FAA report
20230808015419I
Case key
192891

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 separation of the stabilator actuator from the stabilator tab, which resulted in pitch control surface flutter and structural damage.

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.

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

Shortly after takeoff the airplane began to shake violently with the control yoke moving rapidly forward and aft from stop to stop. The pilot was able to perform an on-airport emergency landing after shutting down the engine, but sustained hand injuries due to the extreme control forces and oscillations. The airplane sustained substantial damage to the stabilator structure in a manner consistent with it exhibiting aerodynamic flutter. Postaccident examination revealed that the stabilator tab actuator was disconnected from the control tab, and the bolt, nut, and washer that connected them were missing. The disconnection of the actuator allowed the tab surface to uncouple, which resulted in flutter and structural damage to the stabilator. Circumferential scoring around the bolt hole within the tabs indicated that the bolt was likely loose for an undetermined period before failure. The nut had likely not been replaced since the airplane was manufactured almost 60 years before the accident, so its locking properties would have been significantly diminished.

Factual narrative

On August 8, 2023, about 1500 Pacific daylight time, a Piper PA-24-260, N503JA, was substantially damaged when it was involved in an accident near Fullerton, California. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that, shortly after takeoff, the airplane began to shake violently with the control yoke moving rapidly forward and aft from stop to stop. The vibrations were so extreme that he assumed the engine had suffered a catastrophic failure, such as a detached engine cylinder. He shut down the engine and turned the airplane back to the airport for landing. The pilot stated he was able to land, but sustained hand injuries due to the extreme control forces and oscillations. The airplane sustained substantial damage to the stabilator structure and postaccident examination revealed that the stabilator tab actuator was disconnected from the control tab, and the bolt, nut, and washer that connected them were missing (figure 1). Figure 1 - Stabilator tab disconnected from the actuator. The tabs sustained extensive scratch and peening damage to both their inner and forward surfaces consistent with high frequency oscillations. The paint around the end of the tab actuator arm had chipped away, revealing similar peening damage to its steel surface. Neither the bolt nor the nut that connected the tabs to the actuator were located, and there was circumferential scoring to the tabs around the bolt hole bore. Neither bolt hole appeared to be elongated. Likewise, the bushing within the actuator did not appear to be out of round. According to the airplane’s illustrated parts catalog, the actuator retaining nut was supposed to be a self-locking type, with no provisions for a cotter pin. The mechanic who had performed an annual inspection 5.5 flight hours before the accident stated that he did not remove or replace either the bolt or the nut, and that he performed a functional check of the pitch trim system with no anomalies noted. Examination of the maintenance logbooks did not reveal any evidence that the nut had been replaced since the airplane was manufactured in 1965.

Aircraft

Registration
N503JA
Reported as
Piper PA-24-260
Category
Airplane
Serial number
24-4165
Built
1965
Airframe hours
3,849.7
Engine
Lycoming IO-540-D4A5, 260 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 1, 2023 · 5.5 hours before
Departed
FUL · Fullerton, CA
Destination
POC · La Verne, CA
Airport
FUL · Fullerton Muni, runway 24, 3,121 × 75 ft, asphalt
Equipment
Data recorder, ADS-B, Stall warning system

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
41
Injuries
Minor
Certificate
Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
April 14, 2022
Seat
Left
Restraint
3-point
Flight hours
2,441.6 total · 125 in this make and model · 2,351.8 as pilot in command · 190 in the last 90 days · 40 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 63 °F
Altimeter
29.96 inHg
Observed at
KFUL
METAR
METAR KFUL 082253Z 19007KT 10SM CLR 29/17 A2996 RMK AO2 SLP145 T02890167=

Docket · 4

The files NTSB released with the investigation on June 20, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.7 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.