Pilot Debrief

TITAN TORNADO I near Spanaway, WA — 2017-04-13

Final reportWPR17LA087
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Date
2017-04-13
Location
Spanaway, WA, USA
Airport
S44
Aircraft
TITAN TORNADO I
Registration
N5131H
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Initial climb

Probable cause

Maintenance personnel’s improper attachment of the aileron system components, which resulted in the pilot's inability to maintain flight control.

NTSB narrative

The pilot reported that after departure for the personal flight, the airplane climbed to about 200 ft above ground level but he could not maintain level flight; he had to apply full right aileron and right rudder. The airplane rolled left, and he simultaneously reduced the engine power and applied forward elevator in an attempt to arrest the roll. Despite his attempts, the pilot could not regain control of the airplane and deployed the ballistic recovery system parachute (BRS). The airplane touched down hard off the airport, and the nose landing gear collapsed. As a result of the impact, the pilot was unable to egress under his own power; the engine continued to run, and the BRS drifted into the propeller. The engine continued to operate until the BRS suspension lines stopped the propeller. The examination of the aileron system revealed that the control tube was disconnected from the control mixer weldment. The stop nut that normally is affixed to the bolt connecting the aileron control tube to the control yoke tube was found on the cabin floor. The bolt end had a hole for a cotter pin, but no cotter pin was located. There were no markings on the nylon insert of the stop nut, which is consistent with the nut not being adequately attached during assembly. During the last condition inspection, about 4 months and 24 flight hours before the accident, an airframe and powerplant mechanic had adjusted the aileron control mixer. It is likely that during that maintenance activity, the nylon hardware was not properly attached to the aileron control tube.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Properly securing the aileron control tube during maintenance could have prevented failure.

NTSB coding

Evidence available

  • 3 docket documents
View NTSB final reportView NTSB docket

Docket documents3

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