Wednesday, August 12, 2020

Loss of Control in Flight: Beech A36 Bonanza, N312LC; accident occurred August 06, 2020 at Kyle-Oakley Field Airport (KCEY), Murray, Kentucky





Aviation Accident Final Report - National Transportation Safety Board

Additional Participating Entity: 
Federal Aviation Administration / Flight Standards District Office; Louisville, Kentucky

Investigation Docket - National Transportation Safety Board:

BenAir LLC


Location: Murray, Kentucky
Accident Number: ERA20CA283
Date & Time: August 6, 2020, 08:15 Local
Registration: N312LC
Aircraft: Beech 36 
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 2 None
Flight Conducted Under: Part 91: General aviation - Instructional

Analysis

The flight instructor and private pilot were practicing a steep spiral that would terminate with a power-off landing. The instructor stated that the pilot had added "quite a bit" of elevator noseup trim to maintain best glide speed during the spiral maneuver. Right before touchdown, the pilot sensed the airplane had a normal than higher descent rate and increased engine power. When power was added, the airplane’s nose pitched up and the airplane rolled “violently” to the left. The airplane’s left wing struck the runway, substantially damaging it. The flight instructor then assumed control of the airplane and reduced the engine power to idle as it departed the left side of the runway. The pilot subsequently taxied the airplane to the ramp uneventfully. Both pilots reported there were no mechanical malfunctions or failures of the airplane that would have precluded normal operation.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot’s failure to maintain control of the airplane during the simulated power off landing, and the flight instructor's delayed remedial action, which resulted in a loss of control and the airplane’s left wing striking the ground.

Findings

Aircraft Landing flare - Not attained/maintained
Personnel issues Aircraft control - Student/instructed pilot
Personnel issues Delayed action - Instructor/check pilot

Factual Information

History of Flight

Landing-flare/touchdown Loss of control in flight (Defining event)
Landing-flare/touchdown Abnormal runway contact
Landing-flare/touchdown Runway excursion

Flight instructor Information

Certificate: Commercial; Flight instructor 
Age: 64,Male
Airplane Rating(s): Single-engine land; Multi-engine land
Seat Occupied: Right
Other Aircraft Rating(s): None 
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane multi-engine; Airplane single-engine
Toxicology Performed: No
Medical Certification: Class 2 With waivers/limitations
Last FAA Medical Exam: January 16, 2020
Occupational Pilot: No 
Last Flight Review or Equivalent: November 1, 2019
Flight Time: 3337 hours (Total, all aircraft), 29.1 hours (Total, this make and model), 3234 hours (Pilot In Command, all aircraft), 42.2 hours (Last 90 days, all aircraft), 15 hours (Last 30 days, all aircraft), 1.1 hours (Last 24 hours, all aircraft)

Pilot Information

Certificate: Private
Age: 32,Male
Airplane Rating(s): Single-engine land 
Seat Occupied: Left
Other Aircraft Rating(s): None 
Restraint Used: 3-point
Instrument Rating(s): Airplane 
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2 Without waivers/limitations
Last FAA Medical Exam: July 17, 2019
Occupational Pilot: No 
Last Flight Review or Equivalent: May 22, 2020
Flight Time: 488 hours (Total, all aircraft), 250 hours (Total, this make and model)

Aircraft and Owner/Operator Information

Aircraft Make: Beech 
Registration: N312LC
Model/Series: 36 A36
Aircraft Category: Airplane
Year of Manufacture: 2004
Amateur Built: No
Airworthiness Certificate: Normal 
Serial Number: E-3560
Landing Gear Type: Retractable - Tricycle 
Seats: 6
Date/Type of Last Inspection: October 11, 2019 Annual 
Certified Max Gross Wt.: 3651 lbs
Time Since Last Inspection: 
Engines: 1 Reciprocating
Airframe Total Time: 968 Hrs at time of accident
Engine Manufacturer: Continental
ELT: Installed, not activated 
Engine Model/Series: IO-550-B
Registered Owner: 
Rated Power: 300 Horsepower
Operator: On file 
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: CEY,577 ft msl 
Distance from Accident Site: 0 Nautical Miles
Observation Time: 08:35 Local 
Direction from Accident Site: 0°
Lowest Cloud Condition: Clear 
Visibility 10 miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 4 knots / 
Turbulence Type Forecast/Actual: None / None
Wind Direction: 350° 
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.1 inches Hg
Temperature/Dew Point: 20°C / 17°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Murray, KY (CEY)
Type of Flight Plan Filed: None
Destination: Murray, KY (CEY)
Type of Clearance: None
Departure Time: 07:00 Local
Type of Airspace: Class E

Airport Information

Airport: Kyle-Oakley Field CEY
Runway Surface Type: Asphalt
Airport Elevation: 577 ft msl
Runway Surface Condition: Dry
Runway Used: 23
IFR Approach: None
Runway Length/Width: 6202 ft / 100 ft
VFR Approach/Landing: Full stop; Simulated forced landing

Wreckage and Impact Information

Crew Injuries: 2 None
Aircraft Damage: Substantial
Passenger Injuries: 
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None 
Latitude, Longitude: 36.664443,-88.372779 (est)

Cessna 172P Skyhawk, N6601K: Incident occurred August 08, 2020 at United States Air Force Academy Airfield (KAFF), Colorado Springs, El Paso County, Colorado

Federal Aviation Administration / Flight Standards District Office; Denver, Colorado

Aircraft landed hard and gear collapsed.

Air Force Academy Aero Club

https://registry.faa.gov/N6601K

Date: 08-AUG-20
Time: 22:45:00Z
Regis#: N6601K
Aircraft Make: CESSNA
Aircraft Model: 172
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: PERSONAL
Flight Phase: LANDING (LDG)
Operation: 91
City: COLORADO SPRINGS
State: COLORADO

Cirrus SR22, N678EC: Accident occurred August 11, 2020 in Lafayette, Tippecanoe County, Indiana




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. Additional Participating Entity: 

Additional Participating Entity: 
Federal Aviation Administration / Flight Standards District Office; Chicago, Illinois 

Investigation Docket - National Transportation Safety Board:

Cavu Holdings LLC

https://registry.faa.gov/N678EC

Location: Lafayette, IN
Accident Number: CEN20CA335
Date & Time: August 11, 2020, 17:20 Local
Registration: N678EC
Aircraft: Cirrus SR22
Injuries: 1 Serious, 1 Minor, 1 None
Flight Conducted Under: Part 91: General aviation - Personal 

Aircraft and Owner/Operator Information

Aircraft Make: Cirrus 
Registration: N678EC
Model/Series: SR22 Undesignated
Aircraft Category: Airplane
Amateur Built: No
Operator: On file
Operating Certificate(s) Held: None
Operator Designator Code:

Meteorological Information and Flight Plan

Conditions at Accident Site: VMC
Condition of Light: Day
Observation Facility, Elevation:
Observation Time:
Distance from Accident Site: 
Temperature/Dew Point:
Lowest Cloud Condition: 
Wind Speed/Gusts, Direction: / ,
Lowest Ceiling: 
Visibility:
Altimeter Setting:
Type of Flight Plan Filed: IFR
Departure Point: Sellersburg, IN (JVY)
Destination: Chicago/Prospect Heights/Wheeling, IL(PWK)

Wreckage and Impact Information

Crew Injuries: 1 Minor 
Aircraft Damage: None
Passenger Injuries: 1 Serious, 1 None
Aircraft Fire: None
Ground Injuries: N/A 
Aircraft Explosion: None
Total Injuries: 1 Serious, 1 Minor, 1 None
Latitude, Longitude: 40.411666,-87.257225

Loss of Control on Ground: Piper PA-28R-200 Cherokee Arrow, N4964S; accident occurred August 08, 2020 at Centennial Airport (KAPA), Arapahoe County, Colorado

 





Aviation Accident Final Report - National Transportation Safety Board

Additional Participating Entity: 
Federal Aviation Administration / Flight Standards District Office; Denver, Colorado

Investigation Docket - National Transportation Safety Board:

Edge Aircraft LLC


Location: Englewood, Colorado
Accident Number: CEN20CA332
Date & Time: August 8, 2020, 11:00 Local 
Registration: N4964S
Aircraft: Piper PA28R
Aircraft Damage: Substantial
Defining Event: Loss of control on ground
Injuries: 2 None
Flight Conducted Under: Part 91: General aviation - Instructional

Analysis

The flight instructor was demonstrating a short approach and touch-and-go landing to the student pilot in a complex airplane. During the final approach, the flight instructor was unable to correct for a quartering tailwind and the airplane landed sideways on the left main landing gear. The flight instructor stated that
"[the landing] felt a bit unusual, but the approach had been stable and the landing wasn't that bad..." The airplane took off and the landing gear would not retract. After troubleshooting the problem and declaring an emergency, the flight instructor landed the airplane with an unsafe landing gear indication. After touchdown, the left main landing gear collapsed, and the flight instructor lost directional control. The airplane impacted taxiway lights and came to rest upright adjacent to the runway. Postaccident examination showed the airplane sustained substantial damage to the left wing. Further examination of the left main landing gear and wing revealed overload damage to the landing gear wing attachment. The flight instructor reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The flight instructor did not maintain a proper approach path and landing flare during a landing with a tailwind, which resulted in a hard landing and damaged landing gear. During the subsequent landing with damaged landing gear, the flight instructor lost directional control which resulted in a runway excursion and collision with objects.

Findings

Personnel issues Aircraft control - Instructor/check pilot
Aircraft Descent/approach/glide path - Not attained/maintained
Aircraft Landing flare - Not attained/maintained
Environmental issues Tailwind - Effect on operation
Aircraft Directional control - Not attained/maintained
Environmental issues Runway/taxi/approach light - Effect on operation

Factual Information

History of Flight

Approach-VFR pattern final Other weather encounter
Landing-flare/touchdown Hard landing
Landing-flare/touchdown Landing gear collapse
Landing-flare/touchdown Loss of control on ground (Defining event)
Landing-flare/touchdown Runway excursion
Landing-flare/touchdown Collision with terr/obj (non-CFIT)

Flight Instructor Information

Certificate: Flight Instructor; Commercial
Age: 43, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 05/01/2019
Occupational Pilot:
Last Flight Review or Equivalent: 06/15/2020
Flight Time: 1428 hours (Total, all aircraft), 140 hours (Total, this make and model), 1381 hours (Pilot In Command, all aircraft), 371 hours (Last 90 days, all aircraft), 104 hours (Last 30 days, all aircraft), 5 hours (Last 24 hours, all aircraft)

Student Pilot Information

Certificate: None
Age: 20, Male
Airplane Rating(s): None
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 04/05/2017
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 230 hours (Total, all aircraft), 0 hours (Total, this make and model), 136 hours (Pilot In Command, all aircraft), 67 hours (Last 90 days, all aircraft), 27 hours (Last 30 days, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: Piper
Registration: N4964S
Model/Series: PA28R 200
Aircraft Category: Airplane
Year of Manufacture: 1970
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 28R-35684
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 06/11/2020, 100 Hour
Certified Max Gross Wt.: 2600 lbs
Time Since Last Inspection: 28 Hours
Engines: Reciprocating
Airframe Total Time: 3816 Hours
Engine Manufacturer: Lycoming
ELT: C126 installed, not activated
Engine Model/Series: IO-360-C1C
Registered Owner: Edge Aircraft Llc
Rated Power: 200 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: APA, 5885 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 0853 MDT
Direction from Accident Site: 0°
Lowest Cloud Condition: Clear
Visibility: 10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 4 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 240°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.19 inches Hg
Temperature/Dew Point: 27°C / -4°C
Precipitation and Obscuration: No Precipitation
Departure Point: Englewood, CO (APA)
Type of Flight Plan Filed: None
Destination: Englewood, CO (APA)
Type of Clearance: VFR
Departure Time: 0952 MDT
Type of Airspace: Class D

Airport Information

Airport: Centennial Airport (APA)
Runway Surface Type: Asphalt
Airport Elevation: 5885 ft
Runway Surface Condition: Dry
Runway Used: 17L
IFR Approach: None
Runway Length/Width: 10001 ft / 100 ft
VFR Approach/Landing: Touch and Go

Wreckage and Impact Information

Crew Injuries: 2 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None
Latitude, Longitude: 39.574444, -104.852222 (est)

Cessna 172S Skyhawk, N657SP: Accident occurred August 01, 2020 at Columbia County Airport (1B1), Hudson, New York

Federal Aviation Administration / Flight Standards District Office; Albany, New York

Aircraft landed hard and incurred propeller strike.

Christiansen Aviation Inc

https://registry.faa.gov/N657SP

Date: 01-AUG-20
Time: 14:00:00Z
Regis#: N657SP
Aircraft Make: CESSNA
Aircraft Model: 172
Event Type: ACCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: SUBSTANTIAL
Activity: PERSONAL
Flight Phase: LANDING (LDG)
Operation: 91
City: HUDSON
State: NEW YORK

MTOSport 2017, N615MW: Accident occurred August 11, 2020 at Springfield Robertson County Airport (M91), Tennessee

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. 

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Nashville, Tennessee

https://registry.faa.gov/N615MW


Location: Springfield, TN
Accident Number: ERA20LA284
Date & Time: 08/11/2020, 0815 CDT
Registration: N615MW
Aircraft: ROTORSPORT UK LTD MTOsport 2017
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Personal

On August 11, 2020, about 0815 central daylight time, a Rotorsport UK LTD MTOsport 2017 gyroplane, N615MW, was substantially damaged when it was involved in an accident near Springfield, Tennessee. The pilot and his passenger were not injured. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

The pilot was interviewed by Federal Aviation Administration aviation safety inspectors, and provided a comprehensive written statement that included charts, diagrams, and photographs. According to the pilot, the gyroplane was loaded 6 pounds below its maximum allowable gross weight when he taxied it for an intersection takeoff from runway 4 at Springfield-Robertson County Airport (M91), Springfield, Tennessee. From that takeoff point, about 2,300 ft. of runway remained available for the takeoff rather than the 5,505 ft. available full-length. At 45 knots, the pilot lifted the nose, and accelerated "in ground effect" for his planned climb speed of 55 knots, but the gyroplane would not accelerate past 48 knots. He further stated, "with the throttle fully advanced, and there was no indication of any engine malfunction."

Because of the published best-angle-of-climb speeds (45-50 knots) the pilot chose to continue the takeoff. As the gyrocopter approached the airport boundary, it had "only climbed to probably 50 [ft]" and was not accelerating. The pilot surveyed the highway that ran perpendicular to the takeoff runway off its departure end, and the powerlines on the far side of the road and chose to perform a forced landing between the airport boundary fence and the road. The gyroplane was substantially damaged during the landing.

The pilot provided performance planning information based on the gyroplane's weight and the atmospheric conditions at the time of takeoff. He then plotted the predicted performance in both plan view and overhead view over graphs and images of the takeoff runway. A review of surveillance video that captured the accident flight revealed that the gyroplane was perhaps 10 feet above the runway surface at the point where it should have been in a steady-state climb and clearing a 50-ft obstacle. From that point, approximately 400 ft of runway and 1,200 ft. of turf runway overrun remained.

The gyroplane was examined by the FAA aviation safety inspectors at the scene and flight control continuity was confirmed. An engine start was attempted on the airframe using the gyroplane's own battery and fuel system. The engine started immediately, accelerated smoothly, and ran continuously without interruption. 

Aircraft and Owner/Operator Information

Aircraft Make: ROTORSPORT UK LTD
Registration: N615MW
Model/Series: MTOsport 2017
Aircraft Category: Gyroplane
Amateur Built:No 
Operator:On file 
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light:
Observation Facility, Elevation: M91, 700 ft msl
Observation Time: 1315 UTC
Distance from Accident Site:
Temperature/Dew Point: 24°C / 21°C
Lowest Cloud Condition: Few / 5000 ft agl
Wind Speed/Gusts, Direction: Calm / ,
Lowest Ceiling:
Visibility:  10 Miles
Altimeter Setting: 30.04 inches Hg
Type of Flight Plan Filed:None 
Departure Point: Springfield, TN (M91)
Destination: Nashville, TN (JWN)

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: 1 None
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion:None 
Total Injuries: 2 None
Latitude, Longitude: 36.536667, -86.921111 (est)



SPRINGFIELD TENNESSEE: (Smokey Barn News) – We are expanding this report after learning about a second emergency landing in Robertson County on Friday.

On Tuesday, a gyrocopter crashed on take-off just outside the Robertson County Airport.

According to the Robertson County Emergency Management Agency, the crash occurred just after 8 am.

Officials tell Smokey Barn News that, after refueling, the MTOSport 2017 in a Northerly takeoff with one passenger onboard, seemed to lack sufficient airspeed for flight causing the gyrocopter to crash or hard land at the end of the runway just outside the airport fence.

The gyrocopter set down feet from Hwy 41 N. The FAA is investigating the crash. The Robertson County Emergency Management Agency is asking the public to stay clear of the wreckage.

The Nashville based pilot, known to frequent the Springfield/Robertson hub, was not injured in the crash. A passenger was also uninjured.

The pilot of the downed gyrocopter was picked up at the scene by another helicopter, officials said.

SECOND CRASH…

The second (or technically the first crash/forced emergency landing) occurred back on Friday when another aircraft (a PA-24-400 Piper Comanche) lost engine power and had to make an emergency landing in a bean field off Dortch Rd near Glen Raven.

According to the Robertson County Emergency Management Agency, the accident occurred just before 5 pm Friday afternoon when the engine lost power and oil sprayed out forcing the pilot to make an emergency landing.

Like the first incident, the pilot was able to successfully land the craft without injury to the pilot or passenger.

https://smokeybarn.com

Just Escapade, N239ZT: Incident occurred August 11, 2020 in Kelso, Cowlitz County, Washington

Federal Aviation Administration / Flight Standards District Office; Portland, Oregon

Aircraft experienced engine failure and made an off airport landing.

https://registry.faa.gov/N239ZT

Date: 11-AUG-20
Time: 20:16:00Z
Regis#: N239ZT
Aircraft Make: JUST AIRCRAFT
Aircraft Model: ESCAPADE
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: MINOR
Activity: PERSONAL
Flight Phase: EN ROUTE (ENR)
Operation: 91
City: KELSO
State: WASHINGTON

System / Components / Malfunction / Failure: Short Brothers SD3-60 Sherpa, N148Z; incident occurred October 13, 2016 at Missoula International Airport (KMSO), Montana








The National Transportation Safety Board did not travel to the scene of this incident.

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Helena, Montana

Aviation Incident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms


http://registry.faa.gov/N148Z  



Location: Missoula, MT 
Incident Number: WPR17IA007
Date & Time: 10/13/2016, 1645 MDT
Registration: N148Z
Aircraft: SHORT BROS SD3 60 SHERPA
Aircraft Damage: Minor
Defining Event: Sys/Comp malf/fail (non-power)
Injuries: 2 None
Flight Conducted Under: Public Aircraft

Analysis 

The airline transport pilots reported that, during a ferry flight of an airplane that had just had been repainted, while on approach at its destination, the nose gear extended but failed to lock and subsequently collapsed on landing.

Postaccident examination of the nose gear confirmed the nose gear's failure to lock, which led to its collapse. Observation of the nose gear down-lock actuator piston revealed that it had been painted, which prevented the piston from engaging and locking the nose gear during extension. Before the flight, maintenance personnel and the flight crew did not observe that the nose gear down-lock actuator piston area was painted.

The airplane manufacturer issued a Service Information Letter (SIL) in 2007, that described a similar incident where the nose gear failed to lock in the down position on the first flight after an airplane had been repainted. The subsequent investigation revealed paint spray on the exposed piston of the nose landing gear down-lock actuator. The SIL stated "ensure that all masking material has been removed from the exposed piston after cleaning/painting, and that the piston is free from any paint or cleaning materials."

Additionally, the landing gear emergency accumulator was observed during the preflight checks to be below the specified pressure. The accumulator was serviced to an adequate pressure prior to takeoff. Subsequently, the pressure bled down during the incident flight, and when the emergency landing gear extension was used by the flight crew, the accumulator did not have adequate pressure. According to the airplane manufacturer, the emergency landing gear extension is reliant on the main system pressure being depleted so that the emergency pressure can change a control valve position. Since the airplane's main hydraulic system was operative during the flight, the inability to use the landing gear emergency extension system, because of the lack of adequate pressure, would have been inconsequential, since the main system pressure was not depleted.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this incident to be:
The failure of the nose landing gear down-lock piston to engage due to paint accumulation, which resulted in a nose landing gear collapse during landing. Also causal was the failure of the facility that performed the painting to comply with manufacturer guidance regarding painting of the airplane. 

Findings

Aircraft
Gear extension and retract sys - Damaged/degraded (Cause)
Nose/tail gear strut/axle - Incorrect service/maintenance (Cause)
Nose/tail gear strut/axle - Inadequate inspection (Cause)

Personnel issues
Scheduled/routine maintenance - Maintenance personnel (Cause)
Incorrect action performance - Maintenance personnel (Cause)
Use of available resources - Maintenance personnel (Cause)

Organizational issues
Oversight of maintenance - Maintenance provider (Cause)

Factual Information

On October 13, 2016, about 1645 mountain daylight time, a Short Bros SD3-60 Sherpa airplane, N148Z, sustained minor damage following a nose gear collapse during landing, at the Missoula International Airport (MSO) Missoula, Montana. The two airline transport pilots, were not injured. The airplane was registered to and operated by United States Department of Agriculture (USDA), as a public aircraft in support of the Forest Service. Visual meteorological conditions prevailed and a visual flight rules (VFR) flight plan was filed for the ferry flight which originated from Kingman Airport, Kingman, Arizona, about 1253.

The pilots reported that prior to landing, they had an unsafe nose gear indication. After multiple unsuccessful attempts to get the nose gear to extend and indicate that it was down and locked, they decided to come in for a landing. During the landing roll, as the airplane's nose was lowered, the nose gear collapsed, and the forward section of the bottom of the fuselage, made contact with the runway surface. Once the airplane came to a stop, both pilots egressed.

Examination of the airplane by the operator revealed minor damage on the underside of the fuselage.

The airplane was returning to MSO, on its first flight, after being re-painted by a vendor in Kingman, Arizona. According to the operator, examination of the nose gear revealed that it failed to lock in the extended position and collapsed during landing. The flight crew attempted to extend and lock the nose gear during the flight but were unsuccessful.

Post incident examination of the nose gear down-lock actuator piston (plunger), revealed that its chrome surface had been painted, which resulted in the locking piston not engaging, and prevented the locking of the nose gear during landing gear extension. The painting of the nose gear down-lock actuator piston was not observed by maintenance personnel or the flight crew on their pre-flight exterior checks.

The airplane manufacturer Shorts issued a SD3-60 Sherpa Service Information Letter (SIL) Sherpa L-23, in April 2007, titled: Servicing/Painting – Removal of masking material/paint from nose landing gear down-lock actuator piston after cleaning/painting operations. The SIL described a similar incident where the nose gear failed to lock in the down position, on the first flight after the airplane had been re-painted. The subsequent investigation revealed paint spray on the exposed chrome piston of the nose landing gear down-lock actuator. The SIL stated "to ensure that all masking material has been removed from the exposed piston after cleaning/painting, and that the piston is free from any paint or cleaning materials."

Additionally, the landing gear emergency accumulator was observed during the pre-flight checks to indicate below the specified pressure. The accumulator was serviced by maintenance to an adequate pressure, prior to takeoff. However, the pressure bled down during the incident flight, and when the emergency landing gear extension was used, the accumulator did not have adequate pressure. According to the operator's maintenance inspector, when activated, a fully serviced emergency accumulator forces the rapid application of hydraulic pressure into the system, however, according to the airplane's manufacturer, this is reliant on the main system hydraulic pressure being depleted so that the emergency pressure can change a control valve position. In this situation, the emergency pressure would be greater than the residual pressure of the failed main hydraulic system.

History of Flight

Prior to flight
Aircraft maintenance event
Aircraft inspection event

Approach
Sys/Comp malf/fail (non-power) (Defining event)

Landing-landing roll
Landing gear collapse 

Pilot Information

Certificate: Airline Transport; Flight Instructor
Age: 58, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Helicopter
Restraint Used:
Instrument Rating(s): Airplane; Helicopter
Second Pilot Present: Yes
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine; Helicopter; Instrument Airplane; Instrument Helicopter
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 11/12/2015
Occupational Pilot: Yes
Last Flight Review or Equivalent: 03/06/2015
Flight Time:  (Estimated) 8715 hours (Total, all aircraft), 148 hours (Total, this make and model), 7755 hours (Pilot In Command, all aircraft), 82 hours (Last 90 days, all aircraft), 12 hours (Last 30 days, all aircraft), 8 hours (Last 24 hours, all aircraft) 

Co-Pilot Information

Certificate: Airline Transport; Flight Instructor; Commercial
Age: 49, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Multi-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 01/25/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 03/02/2016
Flight Time:   (Estimated) 6424 hours (Total, all aircraft), 210 hours (Total, this make and model), 4921 hours (Pilot In Command, all aircraft), 90 hours (Last 90 days, all aircraft), 8 hours (Last 30 days, all aircraft), 8 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: SHORT BROS
Registration: N148Z
Model/Series: SD3 60 SHERPA SHERPA VAR
Aircraft Category: Airplane
Year of Manufacture: 1994
Amateur Built: No
Airworthiness Certificate:
Serial Number: SH3428
Landing Gear Type: Hull; Tricycle
Seats:
Date/Type of Last Inspection:  06/24/2016, Condition
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 2 Turbo Prop
Airframe Total Time: 5203.6 Hours at time of accident
Engine Manufacturer: Pratt & Whitney
ELT: C91 installed, not activated
Engine Model/Series: PT6A-65R
Registered Owner: USDA Forest Service
Rated Power: 1298 hp
Operator: USDA Forest Service
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: MSO, 3206 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1653 MDT
Direction from Accident Site: 0°
Lowest Cloud Condition:
Visibility:  10 Miles
Lowest Ceiling: Overcast / 7000 ft agl
Visibility (RVR):
Wind Speed/Gusts: 6 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 360°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.8 inches Hg
Temperature/Dew Point: 8°C / 1°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: KINGMAN, AZ (IGM)
Type of Flight Plan Filed: VFR
Destination: MISSOULA, MT (MSO)
Type of Clearance: Unknown
Departure Time: 1253 MST
Type of Airspace: Class D

Airport Information

Airport: MISSOULA INTL (MSO)
Runway Surface Type: Asphalt
Airport Elevation: 3206 ft
Runway Surface Condition: Dry
Runway Used: 29
IFR Approach: None
Runway Length/Width: 9501 ft / 150 ft
VFR Approach/Landing: Full Stop

Wreckage and Impact Information

Crew Injuries: 2 None
Aircraft Damage: Minor
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None
Latitude, Longitude: 46.916389, -114.090556 (est)