Pilot Debrief

PIPER PA-28-140 near Burlington, WA — 2013-06-04

Final reportWPR13LA262
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Date
2013-06-04
Location
Burlington, WA, USA
Airport
BVS
Aircraft
PIPER PA-28-140
Registration
N5808U
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Landing

Probable cause

The failure of the rudder bar assembly during landing due to a fatigue crack. Contributing to the accident was the failure of maintenance personnel to perform an adequate inspection of the rudder bar assembly.

NTSB narrative

During the landing roll, the airplane began to veer right, and the pilot applied left rudder and left braking action to align the airplane with the runway; however, both actions were ineffective. The airplane departed the right side of the runway and impacted an airport sign and a ditch. Postaccident examination of the left rudder bar assembly found that it had failed due to a fatigue crack. A rusted brown oxidized area near the center of the crack and surface features consistent with slow-growth fatigue indicated that the crack had been growing incrementally over a period of years. A review of the manufacturer's periodic inspection checklist, maintenance manual, and Service Letter No. 671 indicated that the rudder bar assembly should be inspected every 100 hours specifically for cracks in the area where the airplane's rudder bar failed. If maintenance personnel had inspected the airplane in accordance with these documents, the crack likely would have been found and the accident prevented.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Inspection of rudder control bar should have been performed to prevent failure.

NTSB coding

Evidence available

  • 7 docket documents
View NTSB final reportView NTSB docket

Docket documents7

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