Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; San Jose, California
Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms
Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf
http://registry.faa.gov/N4594J
Accident Number: WPR17LA164
Date & Time: 07/23/2017, 1247 PDT
Registration: N4594J
Aircraft: PIPER PA 28R-180
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal
Analysis
The commercial pilot reported that the accident flight was the first flight following maintenance, which included the installation of right-seat rudder pedals with brake controls. The pilot stated that, during a preflight inspection of the airplane, he actuated the ailerons; however, he did not verify which direction the control yoke moved. He again checked the flight control movement before takeoff but did not verify which direction the aileron moved when he moved the control yoke. During the takeoff sequence, as the airplane became airborne, it immediately entered an uncommanded left roll. The pilot attempted to correct for the roll; however, he was unable to do so and subsequently reduced the engine power. The airplane then impacted the ground and came to rest upright on an adjacent runway.
Postaccident examination of the airplane revealed that, when the control yoke was rotated for input of right aileron, the right aileron moved down, and the left aileron moved up, which is opposite of what would be expected. Examination of the aileron cables revealed that they remained attached to the "T" bar aileron control chains; however, the right aileron control cable was attached to the left aileron control chain, and the left aileron control cable was attached to the right aileron control chain; thus, the cables were connected backward.
The cables were oriented such that they crossed underneath the flap handle and center console area. The two mechanics who performed the maintenance on the airplane reported that they had disconnected the aileron control cables to facilitate the installation of the rudder pedals and brake controls. After completing the maintenance, they checked the flight control cable tension and aileron movement; however, they did not observe which direction the control yoke moved when the aileron was moved. It is likely that the mechanics attached the aileron control cables backward during the reassembly of the aileron control system, which resulted in roll control that was opposite of that commanded by the pilot.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
Maintenance personnel's incorrect installation of the aileron control cables and subsequent failure to verify proper aileron functionality following the maintenance, which resulted in roll control that was opposite of that commanded by the pilot, and the pilot's inadequate preflight inspection, during which he did not verify that the aileron movement matched the control yoke input.
Findings
Aircraft
Aileron control system - Incorrect service/maintenance (Cause)
Aileron control system - Inadequate inspection (Cause)
Personnel issues
Post maintenance inspection - Pilot (Cause)
Post maintenance inspection - Maintenance personnel (Cause)
Installation - Maintenance personnel (Cause)
Factual Information
On July 23, 2017, about 1247 Pacific daylight time, a Piper PA-28R-180, N4594J, was substantially damaged during takeoff from the Reid-Hillview Airport (RHV), San Jose, California. The commercial pilot, sole occupant of the airplane, was not injured. The airplane was registered to Foluain Fabhcun LLC., Aptos, California, and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and no flight plan was filed for the cross-country flight, which was originating at the time of the accident with an intended destination of Marina, California.
The pilot reported that the airplane had just had extensive maintenance performed, which included installation of several avionics upgrades, and right seat brake pedals; the accident flight was the first flight since the maintenance had been completed. During takeoff on runway 31R, as the airplane became airborne at an airspeed of about 80 miles per hour, it immediately entered an uncommanded roll to the left. The pilot said that he attempted to correct for the roll; however, he was unable to, and instead reduced engine power. Subsequently, the airplane impacted the ground and came to rest upright on runway 31L.
Examination of the airplane by a Federal Aviation Administration inspector revealed that the fuselage and left wing were structurally damaged.
Examination of the airplane by the National Transportation Safety Board investigator-in-charge revealed that when the control yoke was rotated for input of right aileron, the left aileron moved upward and the right aileron moved downward. Examination of the aileron cables revealed that they remained attached to the "T" bar aileron control chains. The right aileron control cable was attached to the left side aileron control chain and the left aileron control cable was attached to the right-side aileron control chain. The cables were oriented in a nature that they crossed underneath the flap handle and center console area.
During a telephone conversation with one of the two mechanics that had worked on the airplane prior to the accident flight, he reported that he performed an oil change along with various other work while another mechanic was installing a second set of rudder pedals with brake controls on the right seat side of the airplane. In addition, the mechanic stated that he checked the airplane for flight control cable tension, noting that the operation was smooth, and visually looked at the ailerons while he was moving the control yoke. He added that at no time did he noticed that the aileron cables were installed backwards. The mechanic further reported that all work on the airplane was performed in accordance with the Piper Aircraft Maintenance Manual.
The second mechanic reported that he disconnected aileron cables to facilitate installation of rudder pedals and brake assemblies, and subsequently reattached the aileron cables. The mechanic stated that he did not observe the ailerons while the other mechanic checked aileron control deflections.
During a telephone conversation with the pilot, he reported that prior to the flight, he performed a walk around inspection of the airplane and recalled that he moved the ailerons, but did not verify which direction the control yoke moved. In addition, he said that prior to takeoff, he checked the movement of all the flight controls, but did not verify which direction the ailerons moved when he moved the control yoke. The pilot stated that his primary focus was on the rudder and brakes as they were recently worked on.
History of Flight
Takeoff
Loss of control in flight (Defining event)
Collision with terr/obj (non-CFIT)
Pilot Information
Certificate: Flight Instructor; Commercial
Age: 70, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 07/01/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 05/31/2016
Flight Time: 6000 hours (Total, all aircraft), 5900 hours (Pilot In Command, all aircraft), 30 hours (Last 90 days, all aircraft), 15 hours (Last 30 days, all aircraft)
Aircraft and Owner/Operator Information
Aircraft Manufacturer: PIPER
Registration: N4594J
Model/Series: PA 28R-180 180
Aircraft Category: Airplane
Year of Manufacture: 1968
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 28R-30470
Landing Gear Type: Retractable - Tricycle
Seats:
Date/Type of Last Inspection: Annual
Certified Max Gross Wt.: 2500 lbs
Time Since Last Inspection: 0 Hours
Engines: 1 Reciprocating
Airframe Total Time:
Engine Manufacturer: LYCOMING
ELT:
Engine Model/Series: IO-320 SERIES
Registered Owner: FOLUAIN FABHCUN LLC
Rated Power: 0 hp
Operator: On file
Operating Certificate(s) Held: None
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KRHV, 133 ft msl
Observation Time: 1953 UTC
Distance from Accident Site: 0 Nautical Miles
Direction from Accident Site: 101°
Lowest Cloud Condition: Clear
Temperature/Dew Point: 33°C / 13°C
Lowest Ceiling: None
Visibility: 10 Miles
Wind Speed/Gusts, Direction: Light and Variable, Variable
Visibility (RVR):
Altimeter Setting: 29.83 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: San Jose, CA (RHV)
Type of Flight Plan Filed: None
Destination: Marina, CA
Type of Clearance: None
Departure Time: PDT
Type of Airspace: Class D
Airport Information
Airport: REID-HILLVIEW OF SANTA CLARA C (RHV)
Runway Surface Type: Asphalt
Airport Elevation: 135 ft
Runway Surface Condition: Dry
Runway Used: 31R
IFR Approach: None
Runway Length/Width: 3100 ft / 75 ft
VFR Approach/Landing: None
Wreckage and Impact Information
Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude: 37.333611, -121.821111 (est)
NTSB Identification: WPR17LA164
14 CFR Part 91: General Aviation
Accident occurred Sunday, July 23, 2017 in San Jose, CA
Aircraft: PIPER PA 28R-180, registration: N4594J
Injuries: 1 Uninjured.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
On July 23, 2017, about 1247 Pacific daylight time, a Piper PA-28R-180, N4594J, was substantially damaged during takeoff from the Reid-Hillview Airport (RHV), San Jose, California. The commercial pilot, sole occupant of the airplane, was not injured. The airplane was registered to Foluain Fabhcun LLC., and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and no flight plan was filed for the cross-country flight, which was originating at the time of the accident, with an intended destination of Marina, California.
The pilot reported that this was the airplane's first flight after extensive maintenance, which included installation of several avionics upgrades and right seat brake pedals. During takeoff on runway 31R, as the airplane became airborne at an airspeed of about 80 miles an hour, it immediately entered an uncommanded roll to the left. The pilot said that he attempted to correct the roll, without success, and the airplane impacted the ground.
Examination of the airplane by a Federal Aviation Administration inspector revealed that the fuselage and left wing were structurally damaged. The airplane was recovered to a secure location for further examination.
ReplyDeleteThe obvious is both Pilot and mx people failed to verify proper actuation before flight.
It could happen to me too. Assume nothing is correct if aircraft has had considerable work done.
Folks, verify your controls are free (and correct) before flight.
Sorry to hear. A good aircraft unnecessarily damaged.
I think what saved the pilot's life is that he recognized something wrong and aborted the takeoff early before the airplane got too high. I agree with the above comments and glad the pilot was OK and hope that aircraft will fly again someday as a PA-28R is a great plane
ReplyDelete