NTSB CAROL · Event
Event WPR16IA100
Registry · N200KR
FAA Aircraft Registry record.
Make / Model
PIPER PA-28R-200
Year of manufacture
1976 · 40 years old at event
Engine
LYCOMING O&VO-360 SER (180 hp)
Seats / Engines
4 seats · 1 engine
Last airworthiness date
19760202
ADS-B equipped
Yes — Mode-S A192F4
Registrant of record
DUSEK RYAN
Source: FAA Aircraft Registry (releasable master file).
Aircraft involved
Probable cause & findings
The failure of maintenance personnel to properly install and secure the input swivel boot on the swivel joint, which resulted in excessive vibration that led to fatigue cracks and failure of the throttle cable.
Factual narrative
On April 29, 2016, about 1535 Pacific daylight time, a Piper PA-28-200, N200KR, completed a precautionary landing at the San Carlos Airport (SQL), San Carlos, California following a power control failure. The certified flight instructor (CFI) and the pilot receiving instruction were not injured, and the airplane was not damaged. Visual meteorological conditions prevailed for the instructional flight, which was being conducted in accordance with 14 Code of Federal Regulations Part 91, and a flight plan was not filed. According to the CFI, the intended destination was Byron, California.In a telephone interview with the National Transportation Safety Board (NTSB) investigator-in-charge, the CFI reported that he attempted to reduce power during the initial climb following departure from runway 30 at SQL, but he was only able to make a slight reduction in power. After he determined that no further power reduction was possible, the pilot then flew a right-hand traffic pattern back to runway 30, and on final approach over the runway threshold he fully retarded the mixture control to stop the engine. After landing, the airplane completed its landing roll with sufficient momentum to exit the runway at an intersecting taxiway. A subsequent inspection of the throttle control revealed that the cable had broken. The cable was subsequently recovered by a Federal Aviation Administration aviation safety inspector for further examination by the NTSB. The throttle cable was sent to the National Transportation Safety Board's Materials Laboratory in Washington, D.C., for examination and analysis. Subsequent to the examination, a Senior NTSB Materials Engineer reported the following: The cable was fractured near the input end. Damage to the conduit revealed two areas of wear contact. The smallest wear contact was located in the lower area and had a flat wear pattern, which corresponded to contact with a smooth surface. The larger of the two areas had a ridged pattern, which indicated that the area made contact with another cable. Individual cable wires were fractured at locations within approximately one-half of a lay length. Portions of the fracture surface on each of the outer wires had relatively smooth fracture features oriented perpendicular to the outer surface with curving boundaries, which are features consistent with fatigue. The fatigue origin for each individual wire was located at the same side relative to the overall cable, and the fatigue region extended across approximately half the diameter in each wire. The core wire fracture features appeared rubbed. The wall of the sleeve was deformed into an oblong shape. Additionally, the overall features of the swivel joint were consistent with bending deformation. A curving deformation mark was observed on one side of the swivel tube, which corresponded to contact with the wall of the sleeve under bending loads on the joint. The axis of the conduit was angled (bent) relative to the axis of the sleeve. Adjacent to the sleeve, the blue outer sheath of the conduit was depressed inward at the outside of the bend. The depression in the outer sheath of the conduit was also visible in a radiograph of the part. Another radiograph of the conduit and sleeve revealed that the sleeve was crimped onto the conduit, and that the inner diameter of the coil and the spacing between coils varied along the length of the sleeve. As assembled, an elastomeric boot covers the swivel joints at each end of the cable assembly. As received, the boot at the input end swivel joint was displaced onto the swivel tube. In comparison, the boot at the output end was received covering the joint, and a hose clamp was in place on the boot. No hose clamp was observed at the input end. During the examination, the hose clamp was removed from the boot at the output end swivel joint, and the boot was displaced onto the output swivel tube. The portion of the boot that covered the swivel joint was flared outward relative to the other end of the boot, and an impression was observed where the hose clamp had been installed. More than two months after the hose clamp was removed, the hose-clamp impression remained visible on the surface, and a slight flare was present at the end that had been covering the swivel joint. In comparison, the boot for the input swivel joint had a uniform outer diameter with no evidence of a flared end or hose clamp impression. Additionally, the input swivel tube had a date stamp 6 days after the accident, which revealed similar features for the boot with no evidence of a hose-clamp impression or flared end. According to the cable manufacturer, the swivel joint boot is an important component to prevent contamination and dampen vibration loads on the cable assembly. The flight instructor reported that he and the pilot receiving instruction departed normally and climbed to an altitude of 1,000 ft above ground level. The pilot completed the after-takeoff checklist and attempted to reduce engine power to a climb power setting; however, the engine was unresponsive to throttle inputs. The pilots returned to the airport, pulled the mixture control to the idle cut-off position when the airplane was over the runway threshold, and landed uneventfully. Examination of the throttle control revealed that the cable had broken. Metallurgical examination showed that the cable was fractured due to fatigue near the input end. Fatigue regions on the wires covered about half the cross-section, consistent with a relatively high stress load on the cable. An elastomeric boot covers the swivel joints at each end of the cable assembly; however, examination revealed that the boot at the input end swivel joint had displaced onto the swivel tube. The boot at the input end lacked the same deformation as the boot at the output end, which indicated that the input end boot had not been installed on the swivel joint for some time before the event. As this boot is used to dampen vibrational loads on the cable assembly, it is likely that the cable fractured from fatigue cracks that initiated and grew due to the excessive vibrations that resulted from the missing boot on the swivel joint. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- C Aircraft-Aircraft power plant-Engine controls-Power lever-Not installed/available - C
- C Aircraft-Aircraft power plant-Engine controls-Power lever-Fatigue/wear/corrosion - C
- C Personnel issues-Task performance-Maintenance-Installation-Maintenance personnel - C
Verbatim from NTSB's published report. Source file
NTSB_2016_WPR16IA100.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (stall, maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
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The Value of Strong Partnerships to Build a Successful Aviation Maintenance Career Pathway Program for Transitioning Military Service Members
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From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
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Computational Analysis of Steady State Aerodynamics of Transonic Truss-Braced Wing Configuration in Deep Stall
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- Semantic Scholar 2025 · Article (Applied Sciences)
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Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
A New Trajectory in UAV Safety: Leveraging Reinforcement Learning for Distance Maintenance Under Wind Variations
In the field of aviation, safety is a critical cornerstone, and the operation of Unmanned Aerial Vehicle (UAV) systems is deeply connected with this principle.
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