WPR24LA268

NTSB accident investigation · Piper PA-34-220T · Minden, NV · August 5, 2024

Accident · No injuriesClass 3 · LimitedFinal report
Date
August 5, 2024, 09:00 local (16:00 UTC)
Place
Minden, NV · On Airport
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N4145BPiper PA-34-220T
Defining event
Takeoff-rejected takeoff: Abnormal runway contact
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
FAA, Piper Aircraft Inc.
FAA report
20240805020819A
Case key
194853

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’s improper preflight inspection of the stabilator trim position, which resulted in a porpoised landing. Contributing to the accident was the maintenance personnel’s improper maintenance of the stabilator trim shaft.

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.

Performance/control parameters: landing flareAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-34-220T: 5 casesAll aircraft: 1,285 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotPiper PA-34-220T: 1 caseAll aircraft: 551 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelPiper PA-34-220T: 2 casesAll aircraft: 320 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 the accident flight was the first flight since the airplane had undergone a recent annual inspection. During the preflight inspection, the pilot conducted a functional check of the stabilator trim with the electric trim control but did not visually verify the stabilator trim position. During the takeoff roll, the pilot noted an anomaly with the stabilator and aborted the takeoff shortly after rotation. During the landing, the airplane porpoised several times and the nose landing gear collapsed. Postaccident examination of the airplane revealed that the stabilator trim wheel indicator was found in the full nose-down position. Flight control continuity was established from the cockpit flight controls to the respective flight control surfaces. Binding was noted when using the stabilator trim wheel and force was needed to rotate the stabilator trim control wheel to the natural position. The examination of the stabilator trim shaft revealed a lack of lubrication and excessive wear on the upper- and lower-barrel mount bearings. The mechanic who conducted the annual inspection reported that no anomalies were noted with the flight controls or the stabilator trim controls. The mechanic reported that he moved the stabilator trim controls to the full nose up position, lubricated the stabilator trim shaft, and then ran the stabilator trim to the full nose down position. During the lubrication of the stabilator trim controls, the mechanic operated the controls while the apprentice lubricated the stabilator trim shaft. However, the apprentice who assisted in the annual inspection reported that he did not recall lubricating the stabilator trim controls. The binding and lack of lubrication on the stabilator trim shaft indicated that the inspection and the lubrication was not conducted in accordance with the manufacturer’s maintenance manual. The anomaly noted in the stabilator by the pilot was likely the trim position being in the full nose-down position and not in the neutral position as per the pilot’s operating handbook.

Factual narrative

On August 5, 2024, about 0900 Pacific daylight time, a Piper PA-34-220T, N4145B, was substantially damaged when it was involved in an accident near Minden, Nevada. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the purpose of the flight was to conduct a maintenance check flight following an annual inspection. During the preflight inspection, he conducted a functional check of the stabilator trim with the electric trim control. He heard the trim motor working; however, he did not visually verify the stabilator trim position. During the takeoff roll, he pulled back on the yoke at the rotation speed of 80 knots, but there was no change in pitch, so he pulled harder. He used the electric trim and had minimal elevation gain. He aborted the takeoff by closing both throttles. The airplane pitched forward, porpoised about four times, and the landing gear collapsed. The airplane’s pilot operating handbook preflight checklist states: “Stabilator & Rudder trim…. Neutral.” Postaccident examination of the airplane revealed buckling and bending on the forward fuselage near left and right wing. Buckling and bending was also observed above the windscreen on the fuselage. The stabilator trim wheel indicator was found in the full nose-down position. A visual examination of the flight control cables was conducted, and no damage was observed. Flight control continuity was established from the cockpit flight controls to the respective flight control surfaces. Subsequent examination of the stabilator trim wheel revealed binding. Force was needed to rotate the stabilator trim control wheel to the neutral position when rotated by hand. Using the airplane’s battery, power was applied to the electric trim controls. When the stabilator trim was placed in the full nose-down position, the electric trim servo was heard operating but would not move the stabilator trim cable. A visual examination of the stabilator trim control cable was conducted; no damage was observed. The empennage flight control cover was removed, and a visual inspection of the trim screw assembly was conducted. Corrosion was observed on the trim screw assembly. The exposed shaft of the trim screw was free of lubrication; the ends exhibited minimal lubrication. The trim screw assembly had radial and axial play when moved by hand, consistent with excessive wear on the upper-and lower-barrel mount bearings. The trim screw assembly was dissembled, and circular grooves were observed on the outer sections of the upper-and lower-barrel mount bearings. According to the mechanic who conducted the annual inspection, no anomalies were noted with the flight controls or the stabilator trim controls. The mechanic’s normal process to check and lubricate the stabilator trim controls was to run the stabilator trim to the full nose-up position, lubricate the stabilator trim shaft, and then run the stabilator trim to the fullnose-down position. During the exam of the stabilator trim shaft, he operated the stabilator trim controls, and his apprentice lubricated the stabilator trim shaft. The apprentice who assisted in the annual inspection reported that he did not recall lubricating the stabilator trim controls. Additionally, he did not conduct a functional check of the stabilator trim controls. According to the manufacturer’s maintenance manual check list, the scheduled maintenance of the fuselage and empennage group stated, “Inspect aileron, rudder, stabilator, and stabilator trim cables and pulleys for routing, safety, condition, and operation. Inspect cable terminals, turnbuckles, guides, and fittings for safety and condition.” The lubrication chart in the maintenance manual also identified that the rudder, stabilator, and trim control wheels be lubricated every 100 hours.

Aircraft

Registration
N4145B
Reported as
Piper PA-34-220T
Category
Airplane
Serial number
34-49142
Built
1999
Airframe hours
1,450
Engines
Continental Motors IO-360, 220 horsepower, reciprocatingContinental Motors IO-360, 220 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Tahoe Seneca LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 5, 2024 · 0 hours before
Airport
MEV · Minden-Tahoe, runway 34, 7,399 × 100 ft, asphalt
Equipment
Auto-pilot, 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
62
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
October 27, 2022
Seat
Left
Restraint
3-point
Flight hours
1,257 total · 906 in this make and model · 1,026 as pilot in command · 7 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 46 °F
Altimeter
30.17 inHg
Observed at
KMEV
METAR
KMEV 051615Z AUTO 00000KT 10SM CLR 24/08 A3017 RMK AO2

Docket · 8

The files NTSB released with the investigation on May 6, 2025, on NTSB’s docket system: statements, records, photos and specialists’ reports. 38.5 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.