Pilot Debrief

PIPER PA-28-140 near Weyers Cave, VA — 2021-04-12

Final reportERA21LA183
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Date
2021-04-12
Location
Weyers Cave, VA, USA
Airport
SHD
Aircraft
PIPER PA-28-140
Registration
N7242F
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Approach

Probable cause

Maintenance personnel’s inadequate inspection of the rudder control system, which resulted in failure of the rudder control assembly and the pilot’s loss of control during a go-around.

NTSB narrative

The pilot reported that, while landing, less than 100 ft above ground level, he felt that the approach was unstable and decided to go around. He smoothly applied full engine power, but the airplane did not gain any altitude and started banking hard to the left. He stated that the airplane was to the left of the runway and that he was applying right aileron and right rudder to level the wings with no effect. The airplane subsequently impacted a fence and trees. The pilot was seriously injured, his passenger received minor injuries, and the airplane was substantially damaged. Examination of the airplane revealed that the rudder bar arm and rudder pedal tube, which were part of the rudder control assembly, had separated near a weld, which displayed a crack where extensive corrosion was visible on the fracture surface. Examination under magnification revealed that the fracture of the rudder arm began with an unknown overload event, and crack growth had occurred slowly. As the crack developed, the fracture surfaces fretted against each other until the crack grew enough to cause the left and right fracture surfaces at the base of the weld to the rudder tube to fail as a hinge point, causing a cup-and-cone failure with fresh substrate at the base of the fracture surface. The airplane had accrued about 11,406 hours as of its most recent 100-hour inspection, which was completed about 3 months before the accident. A review of manufacturer’s published guidance revealed multiple documents that included inspection requirements for the rudder pedals, rudder bar, and rudder bar support assembly, which were readily accessible by maintenance personnel for visual inspection. Review of the airplane maintenance records did not reveal any entries that referenced any of the published inspection requirements for the rudder pedals, rudder bar, and rudder bar support assembly. Even without rudder control, the airplane likely remained controllable; however, given the 6-knot right crosswind that existed at the time of the accident, and the airplane’s proximity to the ground when the failure occurred, it is likely that the failure of the rudder control assembly resulted in the pilot’s loss of control.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot could have opted for a stable approach or executed a go-around earlier.

NTSB coding

Evidence available

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

Docket documents17