ASN Wikibase Occurrence # 278395
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| Date: | Wednesday 25 May 2022 |
| Time: | c 13:40 LT |
| Type: |  Diamond DA42 NG Twin Star |
| Owner/operator: | Diamond Aircraft Sales USA Inc |
| Registration: | N591ER |
| MSN: | 42.081 |
| Year of manufacture: | 2006 |
| Total airframe hrs: | 5371 hours |
| Engine model: | Austro Engine E4B |
| Fatalities: | Fatalities: 0 / Occupants: 1 |
| Aircraft damage: | Substantial |
| Category: | Accident |
| Location: | London International Airport (YXU/CYXU), ON -
 Canada
|
| Phase: | Take off |
| Nature: | Test |
| Departure airport: | London International Airport, ON (YXU/CYXU) |
| London International Airport, ON (YXU/CYXU) | |
| Investigating agency: | TSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
A Diamond DA42 NG, was conducting a first test flight following a major refurbishment at Diamond Aircraft Industries at the London International Airport (CYXU). During the takeoff roll everything appeared to be normal, however as the aircraft nose wheel came off the ground, and the aircraft became airborne it immediately veered to the left. The pilot attempted to correct for the un-commanded movement but was having difficulty maintaining direction control of the aircraft. The pilot declared an emergency and flew the aircraft around for an emergency approach to Runway 27. During the approach the pilot continued to have control difficulties and attempted to land on taxiway Alpha, however he ultimately elected to land straight ahead on the grass. The aircraft touched down hard on the grass breaking off the rudder and the left-wing aileron mass balance weight. The landing gear collapsed and the aircraft slid approximately 265 feet from the initial impact to a final stop. The pilot was not injured.
An examination found that the rudder cables had been installed incorrectly.
*Ex N124TS and built as a DA42 and later modified to NG standards.
Findings as to causes and contributing factors:
1. The apprentice who installed the rudder cable guide tubes did so without the aid of specific procedures, guidance, or supervision. As a result, the rudder cable guide tubes were installed incorrectly, running parallel to each other instead of crossing over at the rear of the fuselage as prescribed in the Airplane Maintenance Manual.
2. When the rudder cables were threaded through the rudder cable guide tubes, they also ran in parallel when connected to the rudder lower mounting bracket in the rear of the aircraft. As a result, the rudder moved in the opposite direction of pilot input.
3. The replacement of the rudder cable guide tubes was not recorded, likely because the overall maintenance task was incomplete at the end of the work shift. As a result, the personnel who later certified the work and conducted the independent inspection were not aware of the guide tube replacement and did not check to ensure it had been completed correctly.
4. During certification of the maintenance work performed, the mis-rigged rudder was not detected due to the assumption that the rudder cables were properly installed, the rudder having a proper range of movement, and that likely only 1 person performed the test for correct range of motion during the dual inspections.
5. It is very difficult to see the rudder surface from the cockpit, and the rudder pedals from the tail area. As a result, the flight control portions of the annual and pre-flight inspections, which were accomplished by a single individual, did not identify that the rudder was rigged in reverse.
6. After takeoff, the aircraft yawed in the opposite direction expected by the pilot. In an attempt to regain directional control of the aircraft, the pilot increased rudder input to the right; however, the aircraft continued to yaw and bank to the left. Consequently, the pilot conducted an emergency landing, which resulted in substantial damage to the aircraft.
Accident investigation:
 |
|
Sources:
https://canadanews-ca.uk/fashion/style-hunter/tsb-investigating-crash-involving-small-plane-at-london-ont-airport.html
https://london.ctvnews.ca/investigators-deployed-to-london-international-airport-after-aircraft-accident-tsb-1.5920266
https://aerossurance.com/air-accidents-incidents/cross-connection-maintenance-error-da42/
https://registry.faa.gov/AircraftInquiry/Search/NNumberResult?nNumberTxt=591ER
https://flightaware.com/live/flight/N591ER/history/20220525/1747Z/CYXU/CYXU
https://cdn.jetphotos.com/full/3/72335_1321687128.jpg (photo)
Location
Media:
Wear is found that results in a rare flying control maintenance task. The aircraft crashes during a post-maintenance check flight. We examine the #humanfactors involved.https://t.co/nh8PIOwnU1 #aviationmaintenance #flightsafety #aviationsafety pic.twitter.com/8Gozhp2Qug
— Aerossurance (@Aerossurance) January 20, 2024
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 27-May-2022 08:00 | gerard57 | Added |
| 27-May-2022 09:04 | RobertMB | Updated [Time, Aircraft type, Registration, Cn, Operator, Location, Nature, Departure airport, Destination airport, Source, Narrative] |
| 01-Jun-2022 08:08 | harro | Updated [Total occupants, Phase, Narrative] |
| 05-Jan-2024 15:52 | harro | Updated [Operator, Other fatalities, Departure airport, Destination airport, Narrative, Accident report] |
| 20-Jan-2024 14:07 | Aerossurance | Updated [Time, Operator, Source, Category] |
| 20-Jan-2024 14:12 | Aerossurance | Updated [Embed code] |
| 20-Jan-2024 14:33 | Aerossurance | Updated [Source, Embed code] |
| 20-Jan-2024 14:36 | Aerossurance | Updated [Embed code] |
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