Aviation Accident Summaries

Aviation Accident Summary MIA06CA139

Fort Lauderdale, FL, USA

Aircraft #1

N428RM

Piper PA-23-250

Analysis

The pilot reported that after takeoff, the landing gear remained extended based on sluggish airplane performance and also lack of indicator lights after attempting to retract the gear using the normal procedures. He attempted to cycle the landing gear and also attempted to extend the landing gear using the emergency hand pump and also by the emergency CO2 blow-down bottle; the results of both were unsuccessful. He further reported hydraulic fluid on the cockpit floor after using the emergency hand pump but postaccident examination of the airplane by the FAA revealed no hydraulic fluid leakage in the cockpit. The pilot was advised by air traffic control that the landing gear appeared retracted but the landing gear doors were open. The flight proceeded to another airport where the airplane was landed with the landing gear retracted. Postaccident examination of the airplane by the FAA revealed a loose B-nut of a flexible hydraulic hose at the nose landing gear actuator; the hydraulic reservoir of the power pack was empty. The hose was tightened, the reservoir was serviced, and the landing gear was cycled 3 times using the emergency hand pump. Misadjustment of the down lock switches for each main landing gear was noted though all gears were down and locked over center during gear extension. The pilot advised the FAA that before the accident, no work was performed to the landing gear, though records indicate the pilot purchased the flexible hydraulic hose that was found to have a loose B-nut. Additionally, in May 2006, and again in August 2006, the pilot requested from 2 separate individuals to check the landing gear. The pilot (not a certificated airframe mechanic), asked the one individual in May 2006 to assist him with a "Main Landing Gear retraction problem he couldn't solve." The pilot provided to the NTSB the name of the mechanic who removed and replaced the flexible hydraulic hose at the nose landing gear actuator which was found to have the loose B-nut. The mechanic (that the pilot stated had replaced the hydraulic hose) reported that he did not perform any work to the landing gear system. The maintenance records did not reflect, and no determination was made as to who removed and replaced the flexible hydraulic hose that was found to have the loose B-nut.

Factual Information

On September 17, 2006, about 1051 eastern daylight time, a Piper PA-23-250, N428RM, registered to FLX LLC, was landed gear-up at the Fort Lauderdale Executive Airport (KFXE), Fort Lauderdale, Florida. Visual meteorological conditions prevailed at the time and a visual flight rules (VFR) flight plan was filed for the 14 CFR Part 91 personal flight from Boca Raton Airport (KBCT), Boca Raton, Florida, to South Bimini Airport, Bimini, Bahamas. The airplane was substantially damaged and the airline transport-rated pilot and two passengers were not injured. The flight originated about 1000, from Boca Raton Airport. The pilot stated that he performed the preflight, taxi, and engine run-up before takeoff using the airplane's "POH." The flight was cleared for takeoff and after takeoff, he raised the landing gear selector handle but noted the airplane was "...sluggish in the climb and not accelerating as I expected." He did not notice any gear indicator lights either green or amber, and attempted to cycle the landing gear with no success. He pumped the emergency hand pump and noticed fluid running out of the "control pedestal" onto the floor boards. Emergency procedures were followed including activation of the emergency gear blow-down bottle in an attempt to lower the landing gear but the cable to activate the blow-down bottle "hung up", and the emergency procedures were unsuccessful. He then elected to return to KBCT where he performed 2 low-passes past the tower. The tower controller advised him the landing gear doors were open but the landing gear appeared to be up and locked. The tower controller would not clear the flight to land at the airport but suggested 2 other airports. The pilot proceeded to KFXE where he also performed a low pass and was also informed that the landing gear doors were open but the landing gear appeared to be up and locked. The flight returned for landing and he briefed the passengers on what to expect and the location of the emergency windows and doors. When landing on the runway was assured, he turned off the fuel selectors, and placed the mixture controls to idle cut-off. The airplane was landed and he and the passengers deplaned after it came to rest. On September 27th, or 10 days after the accident, the airplane was towed to a hangar and examined by several FAA airworthiness inspectors. The examination revealed missing interior side panels, carpeting, and the overhead was missing, "...all light and vent assemblies, the wires for the light were hanging loose and uncovered." The pilot confirmed to the FAA that the condition of the interior of the airplane as seen during the postaccident inspection was the same as it was during the accident flight. The airplane was placed on jacks and with FAA oversight, testing of the landing gear was performed using an emergency hand pump located in the cockpit. While pumping the emergency hand pump in an effort to retract the landing gear, a "...leak was found coming from a [hydraulic] line fitting to the retract side of the nose gear actuator." According to the chief inspector of the facility where the work was being performed, hydraulic fluid leakage was noted inside the belly of the airplane forward of the firewall, and the reservoir of the hydraulic power pack was empty. The FAA inspector also reported, "There was no evidence of a hydraulic fluid leak in the cabin of the aircraft." The B-nut at the nose landing gear actuator was tightened, the hydraulic reservoir of the power pack was serviced, and with the airplane on jacks, the landing gear was cycled 3 times using the emergency hand pump. During all 3 cycles, all landing gears extended to the down and locked position and also retracted. The down and locked light for both main landing gears illuminated during 2 out of the 3 extensions, but each did not illuminate during 1 of the extensions. The down and locked light for the nose landing gear illuminated during all 3 extensions. The chief inspector of the facility where the test was performed attributed this to misadjustment of each main landing gear downlock switch. The ring cover in the cockpit beneath the pilot's seat was noted to be raised and the "D" ring cable used to activate the CO2 cylinder for emergency gear extension was extended approximately 6 inches. The CO2 cylinder was noted to be discharged. An individual who does not have an airframe and/or powerplant (A & P) mechanic certificate(s) who previously worked on the airplane reported that on an unspecified date, the pilot contacted him again and asked to assist with a "Main Landing Gear retraction problem he couldn't solve." On either May 13th or 20th, while at the North Perry Airport (KHWO), the airplane was raised on jacks in a hangar in preparation for gear retraction checks but the jacking procedure was stopped. The airplane was removed from the maintenance hangar and towed to the pilot's hangar. No further work was performed to the airplane at that maintenance facility. According to an airframe and powerplant (A & P) mechanic, on August 11, 2006, he performed work to both engines and also installed overhauled brakes for both main landing gears. Sometime during that day he was asked by the owner/accident pilot to perform a gear retraction test. He advised the owner that he could not do so because he did not have a hangar or jacks. He did not make an entry for the work he performed on the engines and brakes because the owner advised him he "...wasn't holding the log books." The owner/accident pilot came back to him after the accident, presented new logbooks, and asked him to make an entry for the work that he performed on August 11th; he complied with the request. The pilot initially told the FAA inspector that before the accident, no work was performed to the landing gear system. The hose that was found to have the loose B-nut was traced to a facility whose records indicate that the suspect hose was purchased by the pilot on June 15, 2006. The pilot later informed the NTSB that the hose had been removed and replaced by a mechanic, who had not performed a gear retraction test. The individual whom the pilot accused of changing the flexible hose at the nose landing gear reported he did not "...touch any of the gear lines or any other gear components. The plane was sitting on its gear the whole time I was working on it." The work he performed consisted of work to both engines. He also reported that the pilot installed "...sheet metal in the nose baggage compartment." The pilot was not a certificated airframe and/or powerplant mechanic. A review of the maintenance records revealed no entry indicating removal and replacement of the nose landing gear retract flexible hose that was found to have the loose B-nut. The NTSB was initially notified of the occurrence on the day of the accident at approximately 1325, and the damage to the airplane was initially reported by the FAA to be minor; therefore, the NTSB initially classified the occurrence as an incident. Several FAA airworthiness inspectors further inspected the airplane and informed the NTSB that the damage to the airplane was consistent with substantial damage. On October 17, 2006, or 1 month after the date of the accident, the insurance adjuster provided to NTSB copies of 3 repair estimates he had received from 3 separate companies. NTSB review of the 3 repair estimates revealed 2 of the 3 mention the need to replace at least 3 stringers, while the third estimate mentions the requirement to repair or replace all damaged structure.

Probable Cause and Findings

The inadequate installation of a flexible hydraulic hose at the nose landing gear actuator by an unknown person resulting in the total loss of hydraulic fluid, the inability of the pilot to extend the landing gear, and subsequent wheels-up landing.

 

Source: NTSB Aviation Accident Database

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