Pilot Debrief

PIPER PA-46-350P near Xenia, OH — 2013-10-09

Final reportCEN14LA006
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Date
2013-10-09
Location
Xenia, OH, USA
Airport
I19
Aircraft
PIPER PA-46-350P
Registration
N561C
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Landing

Probable cause

The nose landing gear failure as a result of a fatigue fracture of the engine mount nose gear actuator feet in an area detailed in a service bulletin. Contributing to the accident was maintenance personnel’s inadequate completion of the inspection specified in the service bulletin.

NTSB narrative

The pilot reported that when the nosewheel touched the runway during landing, the airplane began to pull quickly to the left. He applied right brake and pulled back on the yoke, but the airplane continued to veer off the left side of the runway. The airplane traveled about 500 feet before the nose gear collapsed back into the wheel well, and the airplane's nose and propeller impacted the ground. The postaccident examination of the airplane revealed that the engine mount in the area of the nose gear actuator feet was fractured. As a result of similar accidents, Piper Aircraft had previously issued a Mandatory Service Bulletin (SB) No. 1103D on February 2, 2011. The purpose of the 100-hour recurring inspection specified in SB 1103D was to determine if cracks had developed on the engine mount in the area of the nose gear actuator feet. The accident occurred about 81 hours of time in service after the SB 1103D was complied with. The postaccident examination of the engine mount revealed that the paint around the engine mount attach feet area was only partially removed and not as specified in the SB. A microscopic examination of the right foot of the engine mount revealed that there were fracture features indicative of fatigue progression in many areas. Although the paint removal was not as thorough as specified in the SB, the area where the fatigue fracture was located was in the area where the paint had been removed and should have been detectable during the inspection.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Failure to properly inspect engine mount as per SB 1103D before flight.

NTSB coding

Evidence available

  • Photos
  • 15 docket documents
View NTSB final reportView NTSB docket

Docket documents15

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