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ASN Wikibase Occurrence # 147405
Last updated: 26 March 2017
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Date:28-JUL-2012
Time:06:15 LT
Type:Silhouette image of generic P180 model; specific model in this crash may look slightly different
Piaggio P.180 Avanti
Owner/operator:Avantair Inc
Registration: N146SL
C/n / msn: 1091
Fatalities:Fatalities: 0 / Occupants: 4
Other fatalities:0
Airplane damage: Substantial
Location:San Diego, CA -   United States of America
Phase: Take off
Nature:Non Scheduled Passenger
Departure airport:Camarillo, CA
Destination airport:San Diego, CA
Narrative:
Upon arrival at Henderson Executive Airport - KHND, Las Vegas, Nevada, the left elevator was found to be missing from the aircraft, a Piaggio P180. The elevator was found on 31 July 2012 by the departure runway at Camarillo, California and had there fore been lost on the previous sector. There were no injuries to passengers or crew.

The twin-engine airplane departed 23 minutes behind schedule to pick up passengers at an intermediate airport (San Diego). 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 (Henderson) 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.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: 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.


Sources:

http://www.airport-data.com/aircraft/N146SL.html
https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20120730X73433&key=1
https://www.oig.dot.gov/library-item/35565
http://aviationweek.com/bca/avantair-failure-cautionary-tale-part-2


Revision history:

Date/timeContributorUpdates
04-Aug-2012 01:02 Geno Added
07-Aug-2012 09:48 FLYINGBROTHER1 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]

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