Pilot Debrief

CESSNA 402C near Fort Lauderdale, FL — 2013-04-01

Final reportERA13LA188
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Date
2013-04-01
Location
Fort Lauderdale, FL, USA
Airport
FXE
Aircraft
CESSNA 402C
Registration
VQ-TIN
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Landing

Probable cause

The disconnection of the nose landing gear actuator, which resulted in the subsequent collapse of the nose landing gear. Contributing to the accident was the repair station’s inadequate maintenance, postmaintenance inspection process, and oversight of the maintenance performed and the lack of communication between the repair station personnel, the operator, and the testing technician.

Contributing factors

Contributing to the accident was the repair station's inadequate maintenance, postmaintenance inspection process, and oversight of the maintenance performed and the lack of communication between the repair station personnel, the operator, and the testing technician.

NTSB narrative

Before the accident flight, maintenance had been conducted on the foreign-registered airplane at a Federal Aviation Administration-authorized repair station. After takeoff, the pilot selected the landing gear to the "up" position. The pilot noticed that the main landing gear retracted but that the nose landing gear did not. He then "completed the emergency check," selected the gear "down" position, and subsequently observed three "gear down and locked" lights illuminate. After discussing the situation with an air traffic controller, the pilot decided to return to the airport to land. The touchdown was normal; however, during the landing roll, as the airplane decelerated, the nose landing gear collapsed, and the airplane's nose and propellers contacted the runway, which resulted in substantial damage to the airplane. Examination of the nose landing gear assembly revealed that the nose landing gear actuator was intact, extended, and undamaged but that the rod end, which had its castellated nut still threaded onto it, was not connected to the nose landing gear drag brace. Review of maintenance records and discrepancy sheets revealed no evidence that maintenance had been performed on the nose landing gear assembly. However, review of worksheets that the operator had given to the repair station indicated that the operator had requested that nondestructive testing (NDT) be performed on the nose landing gear drag brace. Although the worksheets were supposed to be used to document the inspections, repair station personnel did not fill them out. However, a work order sent to the operator by the NDT technician, who was a contractor, did indicate that NDT had been performed on the nose landing gear drag brace. The repair station's chief inspector stated that, for previous NDT of the nose landing gear brace, repair station personnel had always removed the part from the airplane. However, after the chief inspector met with the operator's mechanic and the pilot to discuss the maintenance to be performed, they decided that the repair station did not have to be involved in the NDT that day because the nose landing gear brace actually did not need to be removed for the NDT. Thus, the chief inspector did not enter the NDT on the discrepancy sheets. The chief inspector reported that, initially, no one involved in the airplane's maintenance could remember if anyone had worked on or near the nose landing gear; however, a mechanic subsequently reported that he had disconnected and removed the bolt from the nose landing gear actuator at the request of the NDT technician to facilitate the NDT of the nose landing gear. The chief inspector further reported that neither the mechanic nor the NDT technician communicated to anyone that the bolt had been removed or took any actions that might have alerted anyone that the bolt was not in place; evidence indicates that the bolt was not reinstalled, which could have been detected during a postmaintenance inspection. However, the chief inspector reported that, because the nose landing gear drag brace inspection was not on the discrepancy sheet and it had not been removed for maintenance, it did not occur to him to inspect it before releasing the airplane to service. The inspector's failure to inspect the drag brace led to its being returned to service without the bolt attached and its subsequent failure. The evidence indicates that confusion existed regarding what each person's and organization's responsibilities were and that a breakdown in communication occurred between the repair station personnel, the NDT technician, and the operator. These factors, coupled with the lack of oversight by the chief inspector, led to a breakdown in the controls put in place to detect and correct errors before an accident occurs.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Inspection of the nose landing gear drag brace was not performed before release to service.

NTSB coding

Evidence available

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  • 11 docket documents
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Docket documents11

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