Pilot Debrief

PIPER PA-34-200 near West Palm Beach, FL — 2014-01-28

Final reportERA14LA107
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Date
2014-01-28
Location
West Palm Beach, FL, USA
Airport
PBI
Aircraft
PIPER PA-34-200
Registration
N16389
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Landing

Probable cause

The pilot/owner’s failure to maintain the airplane in accordance with a mandatory service bulletin and an airworthiness directive, which resulted in the nose landing gear collapse during landing.

NTSB narrative

The pilot/owner reported that, during the approach, he noted that the nose landing gear (NLG) indication light was not illuminated. He aborted the landing and chose to fly by the air traffic control tower to have a controller check the position of the landing gear. An air traffic controller reported that the landing gear appeared to be down. The airplane was then cleared to land, and, during the landing roll, the NLG collapsed, and the airplane came to rest on the runway. Postaccident examination revealed that there was a hydraulic leak above the NLG actuator and that the NLG drag links were not secured in accordance with the manufacturer's maintenance manual. Over 9 years before the accident, the manufacturer issued a mandatory service bulletin (SB) that required inspections of the NLG, including inspection of the NLG actuator mounting bracket for cracks, elongation of the holes where the retraction link attaches, and loose mounting rivets, and the lubrication of the NLG assembly at a frequency interval not to exceed 50 hours. Subsequently, the Federal Aviation Administration issued an airworthiness directive (AD) requiring the actions contained in the SB. The postaccident examination also revealed that a microswitch appeared to have recently been replaced; however, no associated maintenance entry was found during a review of the airplane's maintenance logbooks. The review did reveal that the airplane's most recent annual inspection was performed about 2 years and 300 flight hours before the accident, that the AD was complied with at that time, and that no defects were noted. No other entries regarding annual inspections or compliance with the SB or AD were noted. Therefore, it is likely that the airplane was not in compliance with the SB or AD at the time of the accident, which likely resulted in the NLG being unable to operate properly and in its collapsing on landing. If the airplane owner had maintained the airplane in accordance with the SB and AD, the hydraulic leak and the improperly secured NLG drag links could have been detected and corrected, which could have prevented the NLG collapse.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Failure to perform required maintenance inspections on the nose landing gear.

NTSB coding

Evidence available

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

Docket documents9

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