Individually Owned: 150,657
Corporate Owned: 137,281
Page Municipal Airport
Aircraft Accident/Incident Report
Page, Arizona 86036
Saturday, April 17, 2004 13:10 MST
NTSB Narrative Summary Released at Completion of Accident
The airplane landed hard after the pilot's control wheel fractured and separated in the landing flare. The pilot said that as he was adding back pressure to flare the airplane his control wheel fractured and separated at the upper left corner. The airplane's nose dropped rapidly and impacted the runway surface first, resulting in the airplane bouncing back into the air. The pilot repositioned his hand behind the broken wheel to the control column and manipulated the broken control yoke forward in an effort to maneuver the airplane back down to the runway surface; the nose landing gear bent and the propeller impacted the runway. The airplane was manufactured in 1962 and equipped with a polymeric control wheel. A metallurgical examination of the fracture surface on the control wheel revealed smooth crack arrest markings along with bands of slightly different colors, indicative of fatigue cracking. The location of the fracture indicated that the fatigue crack propagated as a result of tensile stress from the continual force of the pilot manipulating the control wheel forward and aft. The discoloration and crazing gave evidence of aging effects. The fatigue cracks likely initiated from age related crazed cracks in an area of maximum tensile stresses. The dirt and discoloration of the fracture (and the adjacent cracks and/or crazes), along with the depth of the fatigue crack would suggest that the crack has been in existence for a relatively long time (years, perhaps). Although the fatigue crack would not have been visible from the pilot's viewpoint, it occurred in an area where cracking would be most likely to occur based on the geometry of the yoke. The airplane underwent its last annual inspection 17.76 hours prior to the accident. The airplane manufacturer issued a Service Letter in1964 requiring a one time inspection and proof testing of applicable control wheels. The Service Letter further stated that once control wheels were checked, no further control wheel inspection was required. To show compliance with the Service Letter, a red dot was to be placed on the forward rivet butt on the bottom of the yoke. Both control wheels installed on the accident airplane showed evidence of a red material within the forward rivet butt, indicating that the inspections dictated by the Service Letter were previously preformed. The Federal Aviation Administration issued a Special Airworthiness Information Bulletin (SAIB) in 2001 recommending that during periodic (100-hour or annual) inspections "special emphasis" should be placed on the original plastic control wheels installed in applicable airplanes. If crack indications were "unclear," it recommended that a test be performed in accordance with the manufacturer's Service Letter. The SAIB does not provide a specific location or guidance as to the visual indicators where the cracks are likely to propagate. A review of the Service Difficulty Report (SDR) database revealed a history of 18 control wheel failures in the applicable airplanes, of which a majority reported failures that occurred during a critical phase of flight, including: takeoff, initial climb, spin recovery, and landing flare. Five of the reported failures occurred after the issuance of the SAIB.
NTSB Probable Cause Narrative
the fatigue fracture and separation of the pilot's control wheel, which resulted in a momentary loss of control and a hard landing.
Event Information
| Type of Event | Accident |
| Event Date | 4/17/2004 |
| Event Day of the Week | Saturday |
| Time of Event | 1310 |
| Event Time Zone | Mountain Standard Time |
| Event City | PAGE |
| Event State | ARIZONA |
| Event Country | -- |
| Zipcode of the event site | 86036 |
| Event Date Year | 2004 |
| Event Date Month | 4 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 365557N |
| Event Location Longitude | 1115000W |
| Event Location Airport | Page Municipal Airport |
| Event Location Nearest Airport ID | PGA |
| Indicates whether the acc/inc occurred off or on an airport | On Airport |
| Distance from airport in statute miles | -- |
| Degrees magnetic from airport | -- |
| Airport Elevation | 4313 |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1256 Pacific Standard Time |
| Direction of event from weather observation facility (degrees) | -- |
| Weather Observation Facility ID | PGA |
| Elevation of weather observation facility | 4313 |
| Distance of event from weather observation facility (units?) | -- |
| Time Zone of the weather observation | PST |
| Lighting Conditions | Day |
| Lowest Ceiling Height | -- |
| Lowest Non-Ceiling Height | -- |
| Sky/Lowest/Cloud Conditions | Clear |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 10 |
| Air Temperature at event time (in degrees celsius) | 23 |
| Dew Point at event time (in degress fahrenheit) | -8 |
| Wind Direction (degrees magnetic) | 200 |
| Variable Wind Indicator | Wind direction could be determined |
| Wind Speed (knots) | 17 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Gusting |
| Wind Gust (knots) | 27 |
| Altimeter Setting at event time (in. Hg) | 29.8 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | -- |
| Event Highest Injury | None |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | -- |
| Injury Total Minor | -- |
| Injury Total None | 2 |
| Injury Total Serious | -- |
| Injury Total All | -- |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 19744 |
| NTSB Notification Source | FAA |
| NTSB Notification Date | Apr 23 2004 12:00AM |
| NTSB Notification Time | 1327 |
| Fiche Number and/or location -used to find docket information | DMS |
| Date of most recent change to record | May 30 2006 1:54PM |
| User who most recently changed record | NTSB\JOHB |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | WP-SDL-FSDO |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N1815Z |
| NTSB Number | LAX04LA194 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | None |
| Flight plan Was Activated? | -- |
| Damage | Substantial |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | Cessna |
| Aircraft Model | 205 |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 205-0015 |
| Certified Max Gross Weight | 3300 |
| 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 | 6 |
| Number of Engines | 1 |
| Fixed gear or retractable gear | Fixed |
| Aircraft, Type of Last Inspection | Annual |
| Date of Last Inspection | Jul 1 2003 12:00AM |
| Airframe hours since last inspection | 17.76 |
| Airframe Hours | 3966 |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | No |
| ELT Type | -- |
| Aircraft Owner Name | William Malm |
| Aircraft Owner Street Address | -- |
| Aircraft Owner City | Livermore |
| Aircraft Owner State | CO |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 80536 |
| 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) | Personal |
| Second Pilot on Board | No |
| Departure Point Same as Event | No |
| Departure Airport Code | 3V5 |
| Departure City | Fort Collins |
| Departure State | CO |
| Departure Country | USA |
| Departure Time | 830 |
| Departure Time Zone | CDT |
| Destination Same as Local Flt | crash at destination city |
| Destination Airport Code | PGA |
| Destination City | PAGE |
| Destination State | AZ |
| Destination Country | USA |
| Specific Phase of Flight | Landing - flare/touchdown |
| Report sent to ICAO? | No |
| Evacuation occurred | No |
| Date of most recent change to record | Mar 24 2006 12:03PM |
| User who most recently changed record | COOS |
| Since inspection or accident | Time of Accident |
| Event Location Runway Number and Location | 15 |
| Runway Length | 5157 |
| Runway Width | 150 |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |