Pilot Debrief

PIPER PA28 near San Carlos, CA — 2016-04-29

Final reportWPR16IA100
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Date
2016-04-29
Location
San Carlos, CA, USA
Airport
SQL
Aircraft
PIPER PA28
Registration
N200KR
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Initial climb

Probable cause

The failure of maintenance personnel to properly install and secure the input swivel boot on the swivel joint, which resulted in excessive vibration that led to fatigue cracks and failure of the throttle cable.

NTSB narrative

The flight instructor reported that he and the pilot receiving instruction departed normally and climbed to an altitude of 1,000 ft above ground level. The pilot completed the after-takeoff checklist and attempted to reduce engine power to a climb power setting; however, the engine was unresponsive to throttle inputs. The pilots returned to the airport, pulled the mixture control to the idle cut-off position when the airplane was over the runway threshold, and landed uneventfully. Examination of the throttle control revealed that the cable had broken. Metallurgical examination showed that the cable was fractured due to fatigue near the input end. Fatigue regions on the wires covered about half the cross-section, consistent with a relatively high stress load on the cable. An elastomeric boot covers the swivel joints at each end of the cable assembly; however, examination revealed that the boot at the input end swivel joint had displaced onto the swivel tube. The boot at the input end lacked the same deformation as the boot at the output end, which indicated that the input end boot had not been installed on the swivel joint for some time before the event. As this boot is used to dampen vibrational loads on the cable assembly, it is likely that the cable fractured from fatigue cracks that initiated and grew due to the excessive vibrations that resulted from the missing boot on the swivel joint.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Power reduction attempt during initial climb could have led to a return to the airport sooner.

NTSB coding

  • Sys/Comp malf/fail (non-power) · Initial climb
  • Maintenance

Evidence available

  • 3 docket documents
View NTSB final reportView NTSB docket

Docket documents3

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