ASN Wikibase Occurrence # 147405
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| Date: | Saturday 28 July 2012 |
| Time: | 08:32 |
| Type: |  Piaggio P.180 Avanti |
| Owner/operator: | Avantair Inc |
| Registration: | N146SL |
| MSN: | 1091 |
| Year of manufacture: | 2004 |
| Total airframe hrs: | 8352 hours |
| Engine model: | P&W PT6A SER |
| Fatalities: | Fatalities: 0 / Occupants: 4 |
| Aircraft damage: | Substantial |
| Category: | Accident |
| Location: | San Diego, CA -
 United States of America
|
| Phase: | Take off |
| Nature: | Passenger - Non-Scheduled/charter/Air Taxi |
| Departure airport: | San Diego, CA (KSAN) |
| Henderson, NV (KHND) | |
| Investigating agency: | NTSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
The twin-engine airplane departed 23 minutes behind schedule to pick up passengers at an intermediate airport. During the takeoff roll, the left elevator departed the airplane and was found off the side of the runway 3 days later. The crew arrived at the intermediate airport and quickly boarded the two waiting passengers. They did not perform an adequate preflight inspection and departed about 5 minutes behind schedule. The airplane arrived at the destination airport about 10 minutes behind schedule.
Upon postflight examination by the crew, the left elevator was observed missing from the tail’s horizontal stabilizer. An examination of the attachment nuts on the hinges of the right elevator found that they were finger tight. Examination of the hinge fittings on the left elevator and horizontal stabilizer revealed no mechanical damage or deformation to any of the components. Review of airplane maintenance records showed that an airworthiness directive (AD) had been complied with 54 days earlier, which involved both elevators being removed and then reinstalled.
Materials laboratory examination of one of the right elevator attachment hardware bolt-nut combinations revealed that the self-locking nut exhibited run-on torque values well below the acceptable minimum torque. Based on the finger tight condition of the right elevator attachment hardware and the lack of any mechanical damage to the hinge fittings of the left elevator and stabilizer hinge structure, it is likely that all four sets of attachment hardware for both elevators were not properly torqued during the AD maintenance 54 days earlier. Additionally, 26 days before the event, a phase inspection was completed during which the elevator should have been visually inspected and functionally checked. The airplane had flown 158.9 hours with loose elevator attachment hardware before the two sets of bolts on the left elevator had completely worked their way out of the hinges, and the elevator departed the airplane.
The cockpit voice recorder revealed that the flight crew had experienced unusual pitch control responses during each of the departures and landings. The flight crew could have identified the missing elevator during a preflight inspection at the intermediate airport, yet they decided to continue the flight despite the pitch control problems experienced during the takeoffs and landing.
Probable Cause: The failure of maintenance personnel to properly torque the elevator attachment hardware in accordance with the maintenance manual, which led to the detachment of the elevator. Contributing to the accident were maintenance personnel’s failure to identify the loose attachment hardware during a scheduled inspection, the flight crew’s decision to continue the flight after identifying a flight control problem, and the flight crew’s failure to perform an adequate preflight inspection at the intermediate airport.
The Director of Maintenance was subsequently convicted for obstructing the NTSB investigation.
Accident investigation:
 |
|
Sources:
NTSB
http://aerossurance.com/safety-management/guilty-plea-obstructing-ntsb/
Location
Media:
#OTD in 2017: Director of Maintenance Pleads Guilty To Obstructing an #NTSB Air Accident Investigation.https://t.co/P84ir4v0L5 #flightsafety #aviationsafety #aviationmaintenance pic.twitter.com/fA2oHltndZ
— Aerossurance (@Aerossurance) March 10, 2021
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 04-Aug-2012 01:02 | Geno | Added |
| 07-Aug-2012 09:48 | Alpine Flight | Updated [Time, Aircraft type] |
| 08-Aug-2012 23:59 | Yespiaggio | Updated [Narrative] |
| 21-Dec-2016 19:28 | ASN Update Bot | Updated [Time, Damage, Category, Investigating agency] |
| 20-Mar-2017 19:29 | Aerossurance | Updated [Time, Departure airport, Destination airport, Source, Narrative] |
| 20-Mar-2017 19:32 | Aerossurance | Updated [Source] |
| 27-Nov-2017 20:56 | ASN Update Bot | Updated [Time, Other fatalities, Departure airport, Destination airport, Source, Narrative] |
| 10-Mar-2021 08:24 | Aerossurance | Updated [Other fatalities, Source, Embed code, Narrative] |
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