National Transportation Safety Board (

Aviation Accident Final Report (

Location: Brunswick, North Carolina Accident Number: ERA16LA209

Date & Time: June 10, 2016, 09:00 Local Registration: N2283M
Aircraft: WSK PZL MIELEC M 18A Aircraft Damage: Destroyed
Defining Event: Aircraft structural failure Injuries: 1 Fatal
Flight Conducted
Part 137: Agricultural
Under:

Analysis
The experimental, restricted-category airplane impacted wooded terrain after a separation of the right
wing during an aerial application flight. The right wing separated under normal loading conditions due
to extensive pre-existing fatigue cracking in the right outboard wing forward spar lower fitting as the
result of corrosion in the hole bores. In addition, the outboard half of the right aileron separated during
the accident sequence due to fatigue cracking in the right outboard aileron bracket.

Examination revealed evidence of moderate to severe corrosion throughout the airplane. Given the
amount of fatigue cracking and the individual crack features of the spar fitting, it is likely that the
cracking was present for an extended period of time before the final separation and also likely would
have been visible during previous inspections. Maintenance records indicated that the airplane received
an annual inspection about 6 months before the accident and inspection of the wing fittings in
accordance with a Federal Aviation Administration airworthiness directive; however, these inspections
failed to detect the pending failure of the right wing, indicating that they were performed inadequately or
improperly. The maintenance records also indicated that the wing fittings on the accident airplane had
been replaced on three occasions in the 15 years before the accident, indicating that proper cleaning and
corrosion prevention procedures were not being performed.

The airplane was operated over its certificated maximum gross weight on the accident flight and likely
had been operated overweight for much of its lifetime. About 11 years before the accident, the airplane
was outfitted with a larger hopper, increasing its capacity from 660 gallons to 800 gallons. While the
increased hopper volume is beneficial for operation with lower-density solid or dry chemicals, it could
easily be loaded with up to twice the certificated weight of liquid chemicals. Although the manufacturer
published provisions for increasing the operating weight of the airplane, it required that the airframe
service life limit of 10,000 hours be reduced by a factor of 1.35. Review of maintenance records
indicated that not only did the operator not apply any service life limit factors to account for the
overweight operation but that a reduction in overall airframe time was annotated several years before the
accident; this reduction could not be reconciled based on the information presented in the records. Given
the lack of information about its operating history, the actual service life of the airplane could not be
determined; however, it is likely that the airplane was close to or had exceeded its service life,

Page 1 of 13 %
particularly given the overweight operation. Although the failed wing fittings had not accumulated the
service life limit due to their replacement, the corrosion found throughout the airplane and its routine
overweight operation would have reduced the true service life of the fittings.

In addition to the increased airframe stress imposed by continuous overweight operation, the airplane
was modified to install a turbine engine many years before the accident. The engine conversion likely
caused more severe flight loads than accounted for in the design of the original radial piston engine-
equipped airplane, further rendering the manufacturer-published service limits inadequate.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The failure of the right wing due to a fatigue fracture of the right outboard wing forward spar lower
fitting. Contributing to the accident was the routine operation of the airplane over its certificated
maximum gross weight and the operator's improper or inadequate maintenance practices, which failed to
apply a service life factor to the airplane to account for its overweight operation and also failed to detect
the extensive corrosion throughout the airplane.

Findings
Aircraft Attach fittings (on wing) - Fatigue/wear/corrosion
Personnel issues Scheduled/routine maintenance - Maintenance personnel
Organizational issues Oversight of maintenance - Operator
Organizational issues Oversight of operation - Operator
Aircraft Maximum weight - Capability exceeded
Aircraft (general) - Fatigue/wear/corrosion

Page 2 of 13 ERA16LA209 %
Factual Information (

HISTORY OF FLIGHT

On June 10, 2016, about 0900 eastern daylight time, an experimental WSK PZL MIELEC M-18A,
N2283M, was destroyed following an inflight separation of the right wing while maneuvering near
Brunswick, North Carolina. The commercial pilot was fatally injured. Visual meteorological conditions
prevailed, and no flight plan was filed for the aerial application flight, which was operated by Canam
Aviators Inc., under the provisions of Title 14 Code of Federal Regulations Part 137. The flight
originated from Bear Pen Airstrip (NC43), Supply, North Carolina, around 0845.

According to ground personnel, the airplane departed with a full load of fertilizer and 45 minutes of fuel
with 30 minutes of reserve fuel. After 1 hour passed and the airplane did not return to the airport, ground
personnel called 911 to report the airplane missing. The airplane was subsequently located in a wooded
area.

PERSONNEL INFORMATION

According to Federal Aviation Administration (FAA) records, the pilot held a commercial pilot
certificate with ratings for airplane single-engine land, airplane multiengine land, instrument airplane,
and rotorcraft-helicopter. He also held an FAA second-class medical certificate, which was issued on
May 13, 2016. At the time of the medical examination, the pilot reported 30,576 total hours of flight
experience. The pilot's logbook was not recovered.

AIRCRAFT INFORMATION

The airplane was manufactured in 1994 and imported to the US, where it was issued a special
airworthiness certificate in the restricted category. The accident operator purchased the airplane in 2003.

The most recent annual inspection was performed on January 15, 2016, at 8,567.9 hours total time in
service. All of the inspection and maintenance entries from October 17, 2012, to the time of the accident
were performed by the same company and mechanic. There were four annual inspections completed in
this timeframe, and all entries specified that the inspections were conducted in accordance with the M-
18 Service Manual. There was no specific information to indicate which of the published inspections
from the manual were performed.

The airplane wing is composed of three sections; the center section and the right and left outboard
sections. The outboard wing sections are connected to the center wing at three points each: two on the
forward spar and one on the aft spar. The center section contains clevis fittings at the forward spar upper
and lower spar caps and a clevis fitting at the aft spar. Corresponding lug fittings on the outboard wing
sections fit into the center wing clevis fittings. The forward spar connections use an expansion mandrel
installed through the bores of the center wing clevis and wing lug fittings. The aft spar connection uses a
bolt installed through the bores of the center wing clevis and wing lug fittings.

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An FAA inspector estimated that the takeoff weight was about 11,787 lbs, using an airplane empty
weight of 5,975 lbs, chemical weight of 4,940 lbs (800 gallons), a fuel weight of 692 lbs (1.5 hours), and
a pilot weight of 180 lbs.

AIRPLANE MODIFICATION AND MAINTENANCE HISTORY

The type certificate for the PZL M-18A was approved by the FAA in September 1987. The maximum
weight was 9,260 lbs with a maximum hopper weight of 3,300 lbs regardless of the hopper capacity.

The original engine was removed from the accident airplane in April 1996 and replaced with a
Honeywell TPE 331 turbine engine driving a Hartzell 3-blade, constant speed, reversing and feathering
propeller in accordance with STC SA09039SC. Geared servo tabs were installed on the ailerons,
elevators, and rudder in accordance with STC SA09063SC as part of the engine conversion. At the time
of the modification, the airplane had accrued 997.0 hours total time in service. The airplane was again
modified in January 2005, in accordance with STC SA09039SC, to install a different Honeywell
TPE331 turbine engine driving a Hartzell 5-blade constant-speed reversing and feathering propeller. The
airplane had accrued 5,153.7 hours total time in service at the time of this modification. The maximum
weight approved as part of the STC was 9,260 lbs with the spray bar installed and 8,800 lbs with the
spreader installed. A modified hopper was also installed at this time, which increased the hopper
capacity to 800 gallons.

A logbook entry at an airframe time of 6,389.0 hours on June 21, 2006, indicated that the service life of
the airplane was increased to 10,000 hours by incorporation of a manufacturer service bulletin. An entry
on October 9, 2009, adjusted the total time in service of the airframe from 7,630 hours to 6,147 hours.
The explanation provided in the entry indicated that the hour meter installed was recording incorrectly.
On February 20, 2014, at an airframe time of 8,042.0 hours, a logbook entry documented the
replacement of both left lower wing attach fittings and expanding mandrel in accordance with SB
E/02.170/2000. On July 2, 2015, a logbook entry documented the replacement of the wing center section
with a used serviceable unit with an estimated total time of 7,460 hours; the airframe time was 8,562.9
hours.

WRECKAGE AND IMPACT INFORMATION

Examination of the wreckage by an FAA inspector revealed that the debris path was oriented from south
to north. The wreckage area was compact except for the right wing and one propeller blade, which were
located about 125 ft east of the main wreckage. The airplane impacted in a nose-down attitude of about
60°. The left wing was located on top of the engine and separated from the fuselage. The fuselage,
cockpit, and hopper were found 10 ft north of the initial impact point. The remainder of the empennage
was found 20 ft north of the cockpit. Small pieces of debris were found within a 50-ft radius of the
initial impact point.

Further examination of the airplane by an NTSB investigator revealed that the right outboard wing
forward spar lower fitting was fractured. Additionally, the right outboard aileron attach bracket was
fractured, and visible cracks were evident on the right center and inboard aileron attach brackets. The
fractured wing fitting, a fractured wing fitting attach bolt, and all three aileron attach brackets were sent
to the NTSB Materials Laboratory Division in Washington, D.C. for analysis.

ADDITIONAL INFORMATION

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Metallurgical Examination

The right outboard wing forward spar lower fitting fractured through the upper and lower arms in the
areas indicated by arrows in figure 1. Each arm contained six vertical bolt holes used to attach the fitting
to the outboard wing forward spar. The fracture in the upper arm intersected the inboard vertical bolt
hole, and the fracture in the lower arm intersected the second vertical bolt hole from the inboard end.
Bench binocular microscope of the fractured arms revealed all the fracture faces contained fatigue
cracks that emanated from the bore of the holes on diametrically opposite sides of each hole, in the areas
indicated by brackets "O" in figure 1.

Figure 1. Right outboard wing forward spar, lower fitting.

Figure 2 shows a photograph of the lower arm fracture faces. The fatigue cracks in the lower arms
initiated from multiple origins along the entire length of the bolt hole, in the areas indicated by brackets
"O" in figure 2. Most of the fatigue crack origins were associated with corrosion pitting in the bore.
Fatigue propagation on each side of the hole was through a 90% of the thickness and terminated in the
areas indicated by dashed lines in figure 2.

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 Figure 2. Right outboard wing forward spar, Lower fitting, Lower arm.

Figure 3 shows a photograph of the upper arm fracture faces. The upper arm fractures contained similar
fatigue cracks with the exception that the fatigue cracks initiated from multiple origins near the lower
portion of the bolt hole. Most of the fatigue crack origins were associated with corrosion pitting in the
bore. The fatigue cracks in the upper arms exhibited better defined fatigue fracture features than those
on the lower arms.

Figure 3. Right outboard wing forward spar, lower fitting, upper arm.

The fractured bolt examined was installed through the third vertical bolt hole in the right outboard wing
forward spar lower fitting. The fracture intersected the root thread portion of the bolt. The fracture face
of the bolt contained fatigue cracks that emanated from multiple origins all around the root portion.

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Fatigue propagation was toward the center of the bolt and extended through about 95% of the bolt cross
section.

Figure 4 shows a photograph of the right outboard aileron attach bracket, which contained a
circumferential fracture in the main tube portion, near the location where the two upper arms were
welded to the main tube. The fracture intersected the aft edges of the welds at the base of the two arms,
indicated by arrows "X" in figures 4. Bench binocular microscope examination of the forward face of
the main tube fracture revealed multiple fatigue cracks that emanated from the outer surface of the main
tube at the aft edges of the welds. Fatigue propagation was through about 50% of the thickness and
extended around about 30% of the tube circumference. Corrosion was noted on the outboard tube
surface.

Figure 4. Right outboard aileron attach bracket.

The right center and inboard aileron attach brackets were intact, but both brackets contained visible
cracks in the white paint layer where the two upper arms were welded to the main tube. The paint was
removed with a commercial paint stripper from the weld areas of the intact brackets. Bench binocular
microscope examination of both intact brackets after paint stripping revealed the presence of corrosion
and intermittent cracks on the outer surface of the welds in the same respective location as the fracture
on the outboard bracket. The cracks were not opened, but examination of the inner face of the main tube
portion for both intact brackets revealed the intermittent cracks did not extend through the thickness.

Manufacturer Information

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The PZL M18 Description and Service Manual provides procedures for maintaining and inspecting the
airplane, including procedures for corrosion prevention and control; particular emphasis was placed on
the cleaning of the airplane, with the statement that "regular and thorough cleaning of both the interior
and exterior of the aircraft is a major part of corrosion control." The instructions for cleaning included
the statement, "particular attention should be given to wing fittings." In addition, the manual provides
instructions for non-destructive inspection of airframe structural fittings, with specific details for the
wing fittings and anti-corrosion protection of the wing fittings. The manual also includes a maintenance
schedule that contains procedures for verifying inspections every 3,000 flight hours, and periodic
inspections at 50, 100 and 500 flight hours. The manual calls for a mandatory annual inspection within
the scope of the 500-hour inspection and special verifying inspections each 3,000 hours of operation.

According to the PZL M18 Aircraft Repair Manual, the airframe has a service life of 10,000 flight
hours. The left aft center-wing-to-fuselage attach fitting has a service life of 3,000 flight hours. The
manual also defines an "Airframe Service Life in Overload Version." The original airframe service life
was calculated for a takeoff weight of 10,340 lbs. There are procedures to increase the takeoff weight to
11,700 lbs, which, according to the manual, "causes higher fatigue wear and drop of service life by 1.35
times." For all operations performed above the standard weight of 10,340 lbs, the operator should
multiply the flight hours by 1.35 to obtain the proper flight hours for calculating the service life of the
airplane.

The manufacturer issued Service Bulletin (SB) E/02.159/97 in 1997 to provide instructions for corrosion
protection of the outboard wing forward spar fittings as a result of findings on four airplanes that were
operated in Greece. The bulletin provides instructions for inspection of the fitting arms where they
attach to the forward spar, removal of any corrosion within limits, and protection of the fittings by
application of a corrosion inhibiting compound. The bulletin also provides instructions for adding an
inspection panel in the lower leading edge of the outboard wing to improve access to the outboard wing
forward spar fittings. The accident airplane did not have the inspection panel specified by this SB.

The manufacturer issued SB E/02.170/2000 in August 2000 to provide instructions for inspection of the
wing attach joints as a result of two accidents in the United States. The accidents were caused by
corrosion in the lower wing attach fittings that resulted in fatigue cracking and failure of a fitting lug.
The SB provides instructions for inspection of the wing fittings for corrosion in the lug bore and on the
exterior surface of the fittings, repair of minor corrosion, inspection for ovalization of the lug holes, and
magnetic particle inspection of the fitting lugs for cracks. The procedures do not require removal of the
outboard wings but do require removal of the expansion mandrels. Procedures are also provided for
replacement of the wing fittings, if necessary, with the recommendation that both left and right pairs of
lower wing fittings should be replaced, even if only one pair has damage beyond limits. There are no
specific procedures for inspection of the vertical holes where the fittings attach to the spar. The
provisions of this SB were subsequently mandated by airworthiness directive (AD) 2000-18-12. The
manufacturer issued Service Letter M18/034/2016 in February 2016 with instructions that only the
magnetic particle inspection method is applicable for the SB and suggesting that the wings be removed
from the airplane to better perform the inspection.

In January 2001, the manufacturer issued SB E/02.172/2001 to provide guidelines for increasing the
service life of the airframe up to 10,000 flight hours for airplanes S/N 1Z001-01 through S/N 1Z028-01,
which included the accident airplane. The SB instructed operators to perform the 3,000-hour special
inspection in the Service Manual with particular attention paid to incorporation of all applicable

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mandatory bulletins on the airplane and corrosion, cracks and wear in the outboard wing-to-center wing
attach fittings.

There are two published Airplane Flight Manuals (AFM) for the airplane: a European Aviation Safety
Agency (EASA)-approved version for those airplanes operating outside the United States, and an FAA-
approved version. The EASA-approved AFM is used by other airworthiness authorities around the
world, and provides for the operation of the airplane at increased gross weights up to 11,700 lbs, with
the stipulation that a service life factor of 1.35 be applied for those flights above 10,340 lbs.

The FAA-approved AFM specifies that the airplane is certificated in the restricted category for
agricultural operations and dispensing fire-fighting materials. The limitations specify a maximum
takeoff and landing weight of 9,260 lbs, a maximum hopper load of 3,300 lbs, a never exceed speed of
151 knots, a maximum cruising speed of 124 knots, maneuvering load factors of +3.4g and -1.4g, and
prohibits operational flights with a person in the mechanic's seat. The FAA AFM does not specify a
service life factor since the airplane is certificated at a gross weight of 9,260 lbs.

FAA Information

In September 2000, the FAA issued Airworthiness Directive (AD) 2000-18-12 to address corrosion and
cracking of the wing attach fittings on all PZL M-18, M-18A, and M-18B airplanes as a result of two
wing separation accidents. The AD required that operators inspect the center wing-to-outboard wing
attach joints for cracks in the lugs, corrosion in the main holes, and ovalization of the main holes every 1
year or 500 hours time in service (whichever occurs first), repair corrosion and apply anti-corrosion
protection, replace the wing attach joints as necessary, and eliminate any ovalization of the wing main
joint holes. The AD specified that the inspection of the main holes must be done using magnetic particle
methods and all other procedures were to be in accordance with manufacturer SB E/02.170/2000. The
procedures published in the SB and AD were focused on the main attach lug and clevis on the wing
fittings and did not specifically address the vertical bolt holes where the fittings attached to the wing or
center section forward spar.

The AD was first complied with on the accident airplane on January 9, 2001, at an airframe total time of
4,195.7 hours. The records indicated that the left and right forward spar, lower wing attach fittings on
the outboard wings, and the center section were replaced with new fittings as a result of the inspection,
along with the wing straps and the left aft center-wing-to-fuselage attach fitting. The upper fittings were
found to be serviceable. SB E/02.170/2000 was also complied with. The most recent AD inspection of
the wing fittings was performed in January 2016, at an airframe total time of 8,567.9 hours, with no
discrepancies noted.

FAA Advisory Circular (AC) 23-13A provides guidance on the fatigue, fail-safe, and damage tolerance
evaluation of metallic structure for normal, utility, acrobatic, and commuter category airplanes. Section
1-6 of the AC is applicable for alterations, modifications, or changes to the design and states, "Changes
to the operational characteristics that may be important for fatigue include higher design airspeeds or
higher average speed. They also include changes to the maximum allowable weight and center of gravity
envelope, changes to the average weight and center of gravity location, and engine or propeller
changes." Further, the section discusses a comparative fatigue analysis that should be performed when a
modifier does not have access to the data from a manufacturer.

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The manufacturer was not able to supply any information on the modification of the M-18A airplane by
installation of a turbine engine, including any changes to the flight loads, fatigue spectrum, or reliability
data. They were aware that there are STC provisions for the modification, but were not consulted for the
modification by the STC holders.

Australian Transport Safety Bureau Investigation

The Australian Transport Safety Bureau (ATSB) investigated an accident involving a PZL Mielec M-
18A airplane that suffered an in-flight failure of the left wing in October 2013. The details of the
investigation can be found in ATSB Report AO-2013-187. The airplane was equipped with a TPE331
turbine engine. They determined that there was fatigue cracking that initiated due to corrosion pitting in
the bore of the left outboard wing forward spar lower fitting attach lug. The fatigue cracking was only
present on one leg of the lug and comprised about 19% of the total cross-sectional area of the fractured
lug. The ATSB used 25 hours of recorded data from the accident airplane to develop a maneuver load
spectrum for comparison with the manufacturer's design load spectrum and the FAA load spectrum for
agricultural operations published in AC 23-13A. Analysis of the load spectrums showed that "the
negative acceleration fraction spectrum correlated well with the other reference spectra, falling between
the FAA and aircraft manufacturer's spectra" and "other than at low acceleration fractions, the positive
acceleration fraction spectrum was significantly greater than both the FAA and aircraft manufacturer's
spectra." The manufacturer calculated the effect of the derived spectrum, flight time, and operating
speed on the airplane's fatigue life and found that the fatigue life could be reduced by a factor of as much
as 3.85.

Additionally, the ATSB found that the airplane had been operated at higher speeds than assumed by the
manufacturer and at weights above the certificated maximum gross weight, that the flight loads imposed
on the airplane were more severe than assumed during design, and that the service life factors were not
appropriately applied for these operations. This resulted in greater fatigue damage than anticipated by
the manufacturer, rendering the service life limits and inspection intervals inadequate for the operation
of the airplane.

History of Flight
Maneuvering-low-alt flying Aircraft structural failure (Defining event)
Maneuvering-low-alt flying Part(s) separation from AC
Uncontrolled descent Collision with terr/obj (non-CFIT)

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Pilot Information
Certificate: Commercial Age: 57,Male
Airplane Rating(s): Single-engine land; Multi-engine Seat Occupied: Single
land
Other Aircraft Rating(s): Helicopter Restraint Used: 3-point
Instrument Rating(s): Airplane; Helicopter Second Pilot Present: No
Instructor Rating(s): Airplane single-engine; Instrument Toxicology Performed: Yes
airplane
Medical Certification: Class 2 With waivers/limitations Last FAA Medical Exam: May 13, 2016
Occupational Pilot: Yes Last Flight Review or Equivalent:
Flight Time: (Estimated) 30576 hours (Total, all aircraft), 99999 hours (Total, this make and model)

Aircraft and Owner/Operator Information

Aircraft Make: WSK PZL MIELEC Registration: N2283M
Model/Series: M 18A B Aircraft Category: Airplane
Year of Manufacture: 1994 Amateur Built:
Airworthiness Certificate: Experimental (Special) Serial Number: 1Z024-25
Landing Gear Type: Tailwheel Seats: 1
Date/Type of Last Inspection: January 15, 2016 Annual Certified Max Gross Wt.: 9260 lbs
Time Since Last Inspection: 350 Hrs Engines: 1 Turbo prop
Airframe Total Time: 8567.9 Hrs as of last Engine Manufacturer: Honeywell
inspection
ELT: Not installed Engine Model/Series: TPE 331-11UA-
Registered Owner: Rated Power: 940 Horsepower
Operator: Operating Certificate(s) Agricultural aircraft (137)
Held:

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Meteorological Information and Flight Plan (
Conditions at Accident Site: Visual (VMC) Condition of Light: Day
Observation Facility, Elevation: KSUT,25 ft msl Distance from Accident Site: 18 Nautical Miles
Observation Time: 08:50 Local Direction from Accident Site: 132°
Lowest Cloud Condition: Clear Visibility 10 miles
Lowest Ceiling: None Visibility (RVR):
Wind Speed/Gusts: 6 knots / Turbulence Type /
Forecast/Actual:
Wind Direction: 310° Turbulence Severity /
Forecast/Actual:
Altimeter Setting: 30.1 inches Hg Temperature/Dew Point: 26°C / 21°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Supply, NC (NC43) Type of Flight Plan Filed: None
Destination: Supply, NC (NC43) Type of Clearance: None
Departure Time: 08:45 Local Type of Airspace: Class E

Wreckage and Impact Information

Crew Injuries: 1 Fatal Aircraft Damage: Destroyed
Passenger Aircraft Fire: None
Injuries:
Ground Injuries: N/A % Aircraft None
Explosion:
Total Injuries: 1 Fatal % Latitude, 34.127498,-78.339721
Longitude:

Administrative Information (
Investigator In Charge (IIC): Boggs, Daniel
Additional Participating Clyde McCullough; FAA; Greensboro, NC
Persons: Tomasz Makowski; State Commission Aircraft Accident Investigation; Warsaw
Janusz Pietruszka; PZL Mielec; Mielec
Original Publish Date: April 17, 2018
Note: The NTSB did not travel to the scene of this accident.
Investigation Docket: https://data.ntsb.gov/Docket?ProjectID=93360

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 The National Transportation Safety Board (NTSB), established in 1967, is an
independent federal agency mandated by Congress through the
Independent Safety Board Act of 1974 to investigate transportation
accidents, determine the probable causes of the accidents, issue safety
recommendations, study transportation safety issues, and evaluate the
safety effectiveness of government agencies involved in transportation. The
NTSB makes public its actions and decisions through accident reports,
safety studies, special investigation reports, safety recommendations, and
statistical reviews.

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b),

precludes the admission into evidence or use of any part of an NTSB report
related to an incident or accident in a civil action for damages resulting from
a matter mentioned in the report. A factual report that may be admissible
under 49 U.S.C. § 1154(b) is available here.

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