Aviation Accident Summaries

Aviation Accident Summary WPR17LA164

San Jose, CA, USA

Aircraft #1

N4594J

PIPER PA 28R-180

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.

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.

Probable Cause and Findings

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.

 

Source: NTSB Aviation Accident Database

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