ANC19LA016

NTSB accident investigation · Piper PA-32-300 · Bethel, AK · April 12, 2019

Accident · No injuriesClass 3 · LimitedFinal report
Date
April 11, 2019, 16:08 local (Apr 12, 2019, 00:08 UTC)
Place
Bethel, AK
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4466TPiper PA-32-300
Defining event
Enroute: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Alaska Regional Office
Parties
Lycoming Engines, Paklook Air Inc, FAA
FAA report
20190411015019A
Case key
99260

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

A total loss of engine power due to a fatigue failure of the crankshaft. A contributing factor was the inadequate inspection during the engine’s last overhaul.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Engine (reciprocating)Aircraft › Aircraft power plant · Fatigue/wear/corrosionPiper PA-32-300: 8 casesAll aircraft: 497 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · FailurePiper PA-32-300: 8 casesAll aircraft: 497 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelPiper PA-32-300: 1 caseAll aircraft: 320 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported that, while in cruise flight, the engine lost partial power, then total power, and the propeller stopped turning. During the subsequent off-airport forced landing on the tundra meadow, the main landing gear separated from the airplane, resulting in substantial damage to the right wing. Examination of the engine revealed a crankshaft failure that was likely a result of fatigue cracking that emanated from the surface of the main journal. The engine was overhauled at a certified repair station about 14 flight hours before the accident. The engine manufacturer overhaul manual stated that the crankshaft was to be inspected using a magnetic particle inspection procedure as part of the overhaul; however, the crankshaft was not inspected as part of the overhaul. It is likely that if the crankshaft had been inspected as indicated, the fatigue cracking would have been detected and corrected during overhaul.

Factual narrative

On April 11, 2019, about 1608 Alaska daylight time, a Piper PA-32-300 airplane, N4466T, sustained substantial damage when it was involved in an accident near Bethel, Alaska. The pilot and three passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 135 domestic passenger flight. The pilot reported that, while en route from Aniak Airport (ANI), Aniak, Alaska, to Bethel Airport (BET), Bethel, Alaska, the engine began to sound “different,” and he observed a loss of engine oil pressure below the green arc. The engine rpm decreased to about 2,000 rpm, and the oil pressure continued to decrease to the yellow arc. As he turned the airplane toward Akiak Airport (AKI), Akiak, Alaska, the closest airport, and while adjusting the propeller rpm, the engine lost all power. During the subsequent off-airport forced landing on the tundra-covered meadow, the main landing gear separated from the airplane, resulting in substantial damage to the right wing. Examination revealed that the engine was seized and could not be rotated. The case halves were separated, revealing a failure of the crankshaft on the No. 3 main bearing journal. The failure showed signs of thermal damage and twisting. The engine valves were all set correctly and properly installed. The oil pan contained large amounts of copper and metal flake. The oil pan screen was removed, and heavily fragmented metal shavings were found. The fractured crankshaft and two halves of a bearing from main journal No. 3 were sent to the NTSB Materials Laboratory. The examination revealed that crack arrest marks typical of fatigue cracking emanated from multiple origins at the surface of the main journal. The fatigue origin area was located near the center of the main journal. The fracture face at the fatigue origin area exhibited evidence of blue, grey, and red tinting consistent with heat exposure. The fracture features at the origin of the fatigue crack and other portions of the fracture were obliterated by post-fracture relative movement between mating fracture faces. The fatigue crack propagated toward the core of the main journal, where it split into two fatigue cracks. The surface of the main journal exhibited evidence of severe mechanical damage such as circumferential abrasion, wear, galling and heat tinting. The surface also contained evidence of ladder cracking. The overhauled engine was installed in April 2019 and had accumulated about 14 hours of operation before the accident. Section 7 of the Lycoming Overhaul Manual for direct drive engines, page 7-4 section 7-28A states: Crankshaft (Magnetic Particle Inspection). Inspect the crankshaft using a magnetic particle inspection procedure performed by a certified operator. The work order for the engine overhaul indicated that a magnaflux and zyglo inspection was completed, but the inspection did not include the case or crankshaft. The owner of the certified repair station stated that they perform allnon-destructive testing (NDT) inspections, magna flux, and measurements for the overhauled engines at their location. After they NDT inspect the parts, “NDT” was stamped on the part. Components without an NDT stamp indicated that NDT inspection was not completed. The accident crankshaft had no visible NDT stamp.

Aircraft

Registration
N4466T
Reported as
Piper PA-32-300
Category
Airplane
Serial number
32-7240067
Built
1972
Airframe hours
19,991.3
Engine
Lycoming IO-540 -K1A5, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Paklook Air Inc, doing business as Yute Commuter Service
Registered owner
Michael W. Renfro
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · April 7, 2019
Departed
ANI · Aniak, AK
Destination
BET · Bethel, AK
Flight plan
Company VFR
Equipment
ADS-B

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
38
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
November 18, 2018
Seat
Left
Flight hours
16,800 total · 80 in the last 90 days · 40 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
50° at 18 knots
Visibility
10 statute miles
Lowest ceiling
6,500 ft broken
Temperature
43 °F, dew point 36 °F
Altimeter
29.04 inHg
Observed at
PAKI, 9 nm away

Docket · 12

The files NTSB released with the investigation on November 4, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 29.9 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N4466T · 1

Matched to the same aircraft by N-number and date.