Casualties unknown

2020-02-18: Piaggio-P180-Avanti (SP-MXH) — Pilot samolotowy zawodowy CPL — Warszawa (EPWA), PL

Warszawa (EPWA), PL

On February 18, 2020, a Piaggio-P180-Avanti (registration SP-MXH) operated by Pilot samolotowy zawodowy CPL was involved in an aviation accident near Warszawa (EPWA), PL. Investigators recorded the probable cause as: The cause of the incident was lack of proper oversight of the stored component. This summary draws on records from the Polish State Commission on Aircraft Accidents Investigation (PKBWL); 8 related events involving the same aircraft type or operator are linked below.

Sourcesthe Polish State Commission on Aircraft Accidents Investigation (PKBWL)Primary reportUpdated 1785092869Data APIEditorial standards
Aircraft registered SP-MXH
Aircraft registered SP-MXH. Photo: Anna Zvereva from Tallinn, Estonia / CC BY-SA 2.0, via Wikimedia Commons

On 18 February 2020, a Piaggio P180 Avanti (SP-MXH) had an elevator trim issue during preflight. Maintenance replaced the actuator with a stored unit that had an expired time limitation, later rectified.

Incident Description

On 18 February 2020, at EPWA Warsaw-Okęcie, a crew from Lotnicze Pogotowie Ratunkowe (LPR) was conducting a preflight inspection of a Piaggio P180 Avanti (registration SP-MXH) before a test flight to verify the rectification of a "SECONDARY PITCH TRIM SYSTEM INOP" defect. During the preflight check, the pilot observed abnormal elevator trim operation: in primary mode, it was not possible to set the trim to the "heavy on tail" position. In backup mode, the trim functioned correctly. The check was performed on both control yokes.

Maintenance Actions

Technical personnel from the Warsaw-Okęcie Maintenance Station diagnosed a faulty Horizontal Tail Trim Actuator (HTTA). An actuator was retrieved from LPR's stores and installed by a mechanic. A test of the stabilizer control was carried out with a positive result. The pilot then performed a test flight (order no. 217), also with a positive outcome. After the maintenance documentation was handed over to the Continuing Airworthiness Management Department, it was discovered that the installed actuator was incorrectly documented. The component had been placed in storage on 7 December 2015 with a time limitation expiring on 23 March 2018. Although the stored actuator bore a green tag with full data (P/N 70220100, S/N D33143) and the "Remarks or Limitations" field read "N/A" (not applicable), the time limitation date in field 12 of the EASA Form 1 (no. AXB34602) indicated the storage expiry. That information was located at the bottom of the actuator's packaging. Consequently, the actuator was removed and a new one installed. Another test flight was conducted with a positive result, and the aircraft was returned to service.

Root Cause

The cause of the incident was lack of proper oversight of the stored component.

Contributing Factors

Improper acceptance of the actuator into inventory by the storekeeper. The receipt tag listed "N/A" in the "Time Limitation" column. The green storage tag also had "N/A" in the "Remarks or Limitations" field. However, the EASA Form 1 contained the storage limitation information, but it was located at the bottom of the packaging.

Recommendations

The investigative body proposed the following preventive recommendations: inform operational and technical personnel of LPR about the incident; during periodic training for LPR technical staff, remind them of the procedures in manual sections MOE 02-0200 (acceptance and inspection of externally sourced components), MOE 02-03-00 (storage, tagging, and release of components), and CAME paragraph 1.9.1 (component oversight). No additional safety recommendations were formulated.

Probable cause

The cause of the incident was lack of proper oversight of the stored component.

Investigation report by the Polish State Commission on Aircraft Accidents Investigation (PKBWL). Original record: https://pkbwl.gov.pl/raporty/2020-0618/. This page is a structured re-presentation; facts and quotes are in the Panstwowa Komisja Badania Wypadkow Lotniczych (PKBWL), Poland.