# NTSB WPR24LA268: Piper PA-34-220T, N4145B, Minden, NV, August 5, 2024 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: August 5, 2024, 09:00 local (16:00 UTC) - Place: Minden, NV · On Airport - Coordinates: 39.0005, -119.7511 - Nearby events: https://openairdocs.org/map.md?lat=39.0005&lon=-119.7511&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff-rejected takeoff: Abnormal runway contact](https://openairdocs.org/ntsb-events/090) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: FAA, Piper Aircraft Inc. - NTSB case key (mKey): 194853 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR24LA268 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/194853/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=194853 - Page: https://openairdocs.org/ntsb/WPR24LA268 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: landing flare](https://openairdocs.org/ntsb-findings/01062041): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-34-220T, 5 cases](https://openairdocs.org/ntsb-findings/01062041/cases.md?model=7103420), [All aircraft, 1,285 cases](https://openairdocs.org/ntsb-findings/01062041/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-34-220T, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=7103420), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-34-220T, 2 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=7103420), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/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: [Piper PA-34-220T, 2 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=7103420), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Takeoff-rejected takeoff: Abnormal runway contact](https://openairdocs.org/ntsb-events/090) (defining event); cases with it: [Piper PA-34-220T, 2 cases](https://openairdocs.org/ntsb-events/090/sequence.md?model=7103420), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) ## 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](https://openairdocs.org/aircraft/N4145B), registered now, S/N 34-49142, built 1999 (OpenAirDocs) - Reported make and model: PIPER PA-34-220T - Registry model: [Piper PA-34-220T](https://openairdocs.org/model/piper-pa-34-220t) (registry code 7103420) (OpenAirDocs) - Registry engine: [Continental TSIO-360 series](https://openairdocs.org/engine/continental-tsio-360-series) (registry code 17019, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 34-49142 - Year built: 1999 - Airframe hours: 1450 - Engines: Continental Motors IO-360 220 horsepower reciprocating; Continental 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: none; 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 ## 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 20240805020819A](https://openairdocs.org/incident/20240805020819A), Aug 5, 2024: Piper PA-34-220T, Minden, NV, Substantial damage. The pilot was performing a post-inspection flight after annual inspection. Upon liftoff from runway 34, the aircraft gained minimal altitude, began to… ## Docket (8 files) The files NTSB released with the investigation on May 6, 2025, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=194853. 38.5 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17765656&FileExtension=pdf&FileName=NTSB%20Form%206120_Redacted-Rel.pdf - Memorandum for record a�� telephone interview, pilot (item 2, PDF, 1 page, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17765431&FileExtension=pdf&FileName=Record%20of%20conversation%20-%20Pilot-Rel.pdf - Record of conversation - maintenance facility (item 3, PDF, 2 pages, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17844907&FileExtension=pdf&FileName=Record%20of%20conversation%20-%20Maintenance%20Facility-Rel.pdf - Airplane maintenance manual (item 4, PDF, 2,484 pages, 33.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18615359&FileExtension=pdf&FileName=MM%20761-888-compressed-Rel.pdf - WPR24LA268 airframe examination (item 5, PDF, 6 pages, 512 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17940073&FileExtension=pdf&FileName=WPR24LA268%20Airframe%20and%20Engine%20Examination_redacted-Rel.pdf - Photo array (item 6, PDF, 7 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17846842&FileExtension=pdf&FileName=WPR24LA268%20Photo%20Array_redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 7, PDF, 14 pages, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17765923&FileExtension=pdf&FileName=Certification%20of%20Party%20Representative_Redacted-Rel.pdf - Evidence control form (item 8, PDF, 1 page, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17765885&FileExtension=pdf&FileName=Evidence%20Form_Redacted-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.