Pilot Debrief

PIPER PA 46 350P near Houston, TX — 2014-12-15

Final reportCEN15LA078
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Date
2014-12-15
Location
Houston, TX, USA
Airport
SGR
Aircraft
PIPER PA 46 350P
Registration
N224JJ
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Landing

Probable cause

The nose landing gear collapse as a result of the fracture of the engine mount at the nose gear actuator attachment point in an area that a service bulletin (SB) recommended for inspection. Contributing to the accident was maintenance personnel’s inadequate compliance with the SB.

NTSB narrative

The pilot reported that, just after landing and as the nosewheel touched the runway, the airplane veered sharply left. The pilot applied right rudder; however, the airplane continued off the left side of the runway. The airplane's nose landing gear (NLG) collapsed, and the airplane came to rest in a grassy area 150 ft from the runway. The examination of the airplane revealed a fractured engine mount in the area of the NLG actuator. As a result of similar accidents, the airplane's manufacturer had issued (about 12 1/2 years before the accident) a mandatory service bulletin (SB), which included a 100-hour recurring inspection to determine if cracks had developed on the engine mount in the area of the NLG actuator feet. The latest version of the SB was issued about 6 months before the accident. A review of the airplane's maintenance records revealed that maintenance personnel had completed the SB inspection during three previous annual inspections; however, there was no record that the SB inspection was conducted during the last annual inspection, which occurred about 6 months before the accident. The accident is consistent with an uncommanded left turn during landing as a result of a broken engine mount. Based on the evidence and the events, it's likely that maintenance personnel did not inspect the engine mount during the most recent annual inspection or that they did inspect the area and missed the cracks that had likely developed on the engine mount.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Failure to document engine mount inspection led to undetected cracks.

NTSB coding

Evidence available

  • 3 docket documents
View NTSB final reportView NTSB docket

Docket documents3

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