Aircraft Accident/Incident Report

Jean, Nevada 89052
Thursday, March 18, 2004 17:17 PST

NTSB Narrative Summary Released at Completion of Accident

The airplane impacted flat desert terrain following an in-flight loss of control. There were no witnesses to the accident. The local solo instructional flight departed about 45 minutes prior to the accident. Recorded radar data indicated that the airplane flew on a southerly course and conducted numerous aerial maneuvers consistent with the type normally practiced during primary flight training. Following the maneuvers, the airplane landed at a nearby uncontrolled airport, then departed again in a northeast direction for 3.8 nm until radar contact was lost. The last radar contact was about 800 feet laterally west of initial impact point, at an above ground altitude of 2,400 feet. The airplane impacted the ground in a steep left bank with a nose low attitude around 30 degrees. The debris field was approximately 100 feet in length, with an energy path opposite in direction to the flight track shown by the recorded radar data. All flight control surfaces were located within the immediate area of the accident site. The right wing separated from the fuselage and was located 30 feet from the fuselage. The right wing aileron balance cable exhibited a tension overload failure inside the right wing. The right wing primary aileron cable was found disconnected at the turnbuckle where it attaches to its corresponding rod end clevis fitting located in the fuselage. The turnbuckle barrel remained attached to the primary cable assembly and the clevis fitting remained attached to the link assembly. The turnbuckle barrel was safety wired on the outboard half that attaches to the primary cable and the safety wire looped back onto itself locking the turnbuckle barrel to the cable. No safety wire or locking device was found on the inboard half of the turnbuckle barrel or clevis fitting. Visual inspection of the threads of both the turnbuckle barrel and the clevis end disclosed that they were undamaged. According to the Piper PA-38-112 parts catalog, the primary cable turnbuckle barrel is to be secured with NAS651-16S locking clips on both sides; however, no clips were found at the accident site or during the subsequent detailed inspection of the wreckage. With the particular configuration of the turnbuckle assembly, it could not be properly secured by the use of safety wire alone. Measurement of the primary right wing aileron cable found that it was not stretched and there was no evidence to indicate that it was connected during the impact sequence. Aircraft records indicated the aileron flight control cable system, including the primary right wing aileron turnbuckle area, were visually inspected at the last 100-hour inspection. The aircraft maintenance records did not have any entries involving the adjustment, removal, or replacement of the aileron flight control cables or components, and the investigation was unable to establish when the safety wire was substituted for the NAS651-16S clips. The three pilots who had flown the airplane on the day before the accident (including one instructional flight and a private pilot practical flight test) reported that there were no discrepancies with the airplane during the flights. The physical evidence is wholly consistent with the primary aileron cable turnbuckle not being connected at ground impact. It is unlikely that the departure from controlled flight that resulted in the ground collision was due to the disconnected aileron cable; however, such a disconnect clearly could hinder any upset recovery effort. Visual meteorological conditions prevailed with no evidence of unusual, hazardous, or violent weather in the area. Evidence clearly shows the engine was producing significant power at ground impact.

NTSB Probable Cause Narrative

The student pilot's failure to regain control of the aircraft following an upset due to the disconnected primary right aileron control cable. The failure of the company maintenance personnel to detect and correct the improperly secured turnbuckle fitting at the last 100-hour inspection is also causal.

Event Information

Type of Event Accident
Event Date 3/18/2004
Event Day of the Week Thursday
Time of Event 1717
Event Time Zone Pacific Standard Time
Event City Jean
Event State NEVADA
Event Country --
Zipcode of the event site 89052
Event Date Year 2004
Event Date Month 3
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 354518N
Event Location Longitude 1151518W
Event Location Airport --
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1745 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 10
Weather Observation Facility ID HND
Elevation of weather observation facility 2492
Distance of event from weather observation facility (units?) 14
Time Zone of the weather observation PDT
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height 27000
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 20
Air Temperature at event time (in degrees celsius) 27
Dew Point at event time (in degress fahrenheit) 1
Wind Direction (degrees magnetic) 8
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 18
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.89
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 1
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 18999
NTSB Notification Source FAA
NTSB Notification Date Mar 19 2004 12:00AM
NTSB Notification Time 734
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Jan 31 2006 7:35AM
User who most recently changed record NTSB\JOHB
Basic weather conditions Visual Meteorological Cond
FAA District Office FAA- FSDO- Las Vegas

Aircraft Involved

Aircraft #1

Aircraft Registration Number N2421D
NTSB Number LAX04FA167
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? No
Damage Destroyed
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Piper
Aircraft Model PA-38-112
Aircraft Series Identifier --
Aircraft Serial Number 38-79A0305
Certified Max Gross Weight 1670
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 2
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection 100 Hour
Date of Last Inspection Jan 1 2004 12:00AM
Airframe hours since last inspection 71
Airframe Hours 5091.2
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Charles F. Herrmann
Aircraft Owner Street Address 1400 Executive Airport Drive, Suite C
Aircraft Owner City Henderson
Aircraft Owner State NV
Aircraft Owner Country USA
Aircraft Owner Zipcode 89052
Operator is an individual? No
Operator Name --
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City --
Operator State --
Operator Country --
Operator Zip code --
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Instructional
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code HND
Departure City Henderson
Departure State NV
Departure Country USA
Departure Time 1636
Departure Time Zone PST
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code --
Destination City --
Destination State --
Destination Country --
Specific Phase of Flight Unknown
Report sent to ICAO? No
Evacuation occurred No
Date of most recent change to record Oct 21 2005 5:30PM
User who most recently changed record COOS
Since inspection or accident Last Inspection
Event Location Runway Number and Location NA
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --