# NTSB ANC23LA005: Piper PA-22-160, N8119D, Kenai, AK, October 27, 2022 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: October 26, 2022, 16:56 local (Oct 27, 2022, 00:56 UTC) - Place: Kenai, AK - Coordinates: 60.542275, -151.19815 - Nearby events: https://openairdocs.org/map.md?lat=60.5423&lon=-151.1981&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Alaska Regional Office - Parties: FAA - NTSB case key (mKey): 106291 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC23LA005 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106291/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=106291 - Page: https://openairdocs.org/ntsb/ANC23LA005 ## Probable cause Improper installation of the crankshaft drive gear by maintenance personnel, who failed to install all required hardware, resulting in an in-flight engine failure. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng rear section](https://openairdocs.org/ntsb-findings/01058540): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-22-160, 1 case](https://openairdocs.org/ntsb-findings/01058540/cases.md?model=7102214), [All aircraft, 42 cases](https://openairdocs.org/ntsb-findings/01058540/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-22-160, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=7102214), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-22-160, 3 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102214), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-22-160, 14 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102214), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis Shortly after takeoff, the engine lost power and the propellor began to windmill. The flight instructor conducted emergency procedures but was unable to regain engine power. The flight instructor determined that they did not have sufficient altitude to make it back to the airport and he selected a road on which to make a forced landing. To avoid a car, the pilot turned slightly towards the edge of the road and was pulled into a snow berm, where the aircraft came to a full stop. The airplane sustained substantial damage to the right wing and fuselage. A postaccident examination of the engine found the crankshaft drive gear bolt was missing and the gear alignment dowel pin on the crankshaft was broken. The missing bolt was not found during the postaccident examination. The engine was last disassembled in 1983 and the accessory gearbox was opened for an oil pump rebuild in 2006; the investigation was not able to identify how long the engine had operated with the bolt missing. The crankshaft drive gear drives the accessory gear box and, according to the engine manufacturer, failure of the gear or the gear attaching parts would result in complete engine stoppage. ## Factual narrative On October 26, 2022, about 1656 Alaska daylight time, a Piper PA-22-160, N8119D, sustained substantial damage when it was involved in an accident in Kenai, Alaska. The flight instructor and the pilot receiving instruction, who was a private pilot, sustained no injuries. The airplane was operated by the instructor pilot as a Title 14 Code of Federal Regulations Part 91 general aviation flight. The purpose of the flight was to conduct pilot training. The airplane took off from the Kenai Municipal Airport, Kenai. Shortly after takeoff, the engine lost total power and the propellor began to windmill. The flight instructor conducted emergency procedures but was unable to regain engine power. The flight instuctor informed the airport tower of their loss of engine power and was cleared to land back at the airport. He determined that they did not have sufficient altitude to make it back to the airport and landed on a road about 2 miles southeast of the airport. During the landing, to avoid a car, the flight instructor turned slightly towards the edge of the road and was pulled into a snow berm where the airplane came to rest. The airplane sustained substantial damage to the right wing and fuselage. A postaccident examination of the engine revealed that the crankshaft drive gear was missing a bolt and a broken dowel pin on the crankshaft. The missing bolt was not found during the postaccident examination. The engine was last disassembled in 1983. The accessory gearbox was opened for an oil pump rebuild in 2006. The crankshaft drive gear drives the accessory gear box and, according to the engine manufacturer, failure of the gear or the gear attaching parts would result in complete engine stoppage. ## Aircraft - Registration: [N8119D](https://openairdocs.org/aircraft/N8119D), registered now, S/N 22-5610 (OpenAirDocs) - Reported make and model: PIPER PA-22-160 - Registry model: [Piper PA-22-160](https://openairdocs.org/model/piper-pa-22-160) (registry code 7102214) (OpenAirDocs) - Category: Airplane - Serial number: 22-5610 - Year built: 1957 - Engines: Lycoming O-360-A4A 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Ham Keith W, doing business as Kenai Aviation Training Academy - Registered owner: Ham Keith W - Airworthiness certificate: Standard, Normal - Departed: PAEN, Kenai, AK - Destination: PAEN, Kenai, AK - Flight plan: VFR - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 31; injuries: none; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land, single-engine sea; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review July 18, 2022; seat: right; restraint: 4-point; flight hours: 963 total, 340.5 in this make and model, 897.5 as pilot in command, 389.3 in the last 90 days, 86.3 in the last 30 days, 1.9 in the last 24 hours - Student pilot; age 17; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review October 17, 2022; seat: left; restraint: 4-point; flight hours: 116 total, 0 in this make and model ## Weather - Conditions: Visual (VMC), Day - Lowest ceiling: none - Temperature: 25 °F - Observed at: PASX - METAR: METAR PAEN 270353Z 15003KT 10SM CLR M04/M04 A2878 RMK AO2 SLP749 T10391039 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20221026013199A](https://openairdocs.org/incident/20221026013199A), Oct 26, 2022: Piper PA-22-160, Kenai, AK, Substantial damage. On 26 October 2022,[privacy data omitted] a PA-22-150 departed Kenai airport(paen) on a part 141 instruction flight with 1 instructor pilot and 1 student pilot… ## Docket (3 files) The files NTSB released with the investigation on October 5, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=106291. 4.7 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14931401&FileExtension=pdf&FileName=ANC23LA005%206120%20Kenai_Redacted-Rel.pdf - Lycoming sb 475C (item 2, PDF, 7 pages, 707 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15591995&FileExtension=pdf&FileName=Crankshaft%2520Gear%2520Modification%2520and%2520Assembly%2520Procedures-Rel.pdf - Photos (item 3, PDF, 3 pages, 716 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14931054&FileExtension=pdf&FileName=Photo%20Array%20ANC23la005-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.