ANC24LA027

NTSB accident investigation · Piper PA-28-151 · Marana, AZ · April 19, 2024

Accident · No injuriesClass 3 · LimitedFinal report
Date
April 19, 2024, 12:30 local (19:30 UTC)
Place
Marana, AZ
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4399XPiper PA-28-151
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, Federal Aviation Administration
FAA report
20240419006069A
Case key
194130

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

The NTSB’s determination of the probable cause, and any contributing factors.

A total loss of engine power due to a failure of the No. 4 cylinder piston boss.

Findings · 1

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

The flight instructor and student pilot were conducting a cross-country flight when the engine began to run rough and make grinding noises. The engine then stopped producing power, and the propeller would not windmill. The instructor attempted to restart the engine and performed a forced landing to a field, during which the airplane sustained substantial damage to both wings. Postaccident examination of the engine revealed significant wear to the camshaft lobes, as well as evidence of catastrophic failure of the No. 4 piston assembly. The damage appeared to originate from the area of the piston pin and boss; however, the failure features were obliterated during the event, preventing an accurate assessment of its origin. The engine was most recently overhauled about 21 years and 2,190 flight hours before the accident. The manufacturer’s recommended time between overhaul (TBO) interval was 2,200 flight hours or 12 years, whichever occurs first.

Factual narrative

The factual narrative605 words

On April 19, 2024, about 1230 mountain standard time, a Piper PA-28 airplane, N4399X, was substantially damaged when it was involved in an accident near Marana, Arizona. The flight instructor and student pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight departed Coolidge Municipal Airport (P08), Coolidge, Arizona, about 1210. The pilot reported that, during cruise flight at about 4,500 ft mean sea level, the engine began to run rough and make grinding noises. The engine stopped producing power and the propeller would not windmill. The flight instructor attempted to restart the engine and performed a forced landing to a field, during which the airplane sustained substantial damage to both wings. Examination of the engine revealed no impact related damage and no evidence of fire. A crack was observed beginning above the No. 3 intake valve tappet casing that propagated through the engine crankcase into the oil sump. The right magneto was detached from its mounting flange. The oil cap was in place and there was no evidence of pre-accident oil leak. Both the engine oil filter media and oil suction screen were coated in shiny metallic particles. Disassembly of the engine revealed catastrophic damage to the No. 4 cylinder and piston assembly, with no significant damage to the remaining cylinders or their associated valvetrain components. The No. 4 cylinder connecting rod was bent 45° at the piston pin end and the piston pin had detached and become embedded in the lower section of the crankcase. Even with this damage, all four connecting rods remained connected to the crankshaft and could be moved smoothly around the crankshaft journal. None of the internal components exhibited evidence of heat distress. The camshaft lobes were worn such that between 10% and 50% of the contact face material had worn away. Metal burrs were present on the edges of the cam lobe remnants, and the associated tappet heads were either shattered or exhibited spalling and cupping deformation to their cam lobe contact faces. The No. 4 piston and pin, along with associated fragments, were examined by a specialist in the NTSB Materials Laboratory. The skirt on the piston underside exhibited the most damage. Approximately half of the skirt material was missing, with the demarcation of fracture located along the bore containing the pin. The lower third of the fracture surfaces of the piston exhibited discernible fracture features, while the rest exhibited reflective lusters with erratic streaks consistent with post-fracture smearing damage from impact or rubbing against adjacent parts. In addition, circular impact witness marks were present on the interior surface of the piston remnant. No pre-existing or progressive cracking features were found on the pin or remnants of the piston. Lycoming Engine Service Instruction No. 1009BE stated that the time between overhaul (TBO) for the O-360 engine was 2,200hours of operation or 12 years (whichever occurred first) and that an engine’s published TBO does not mean that every engine will operate the number of hours or years listed without requiring component replacement and/or unscheduled maintenance events. Noncompliance with instructions for continued airworthiness, operational and/or environmental factors may necessitate repair or replacement of the engine, engine components and accessories earlier than the published TBO. According to the maintenance records, the engine was overhauled by the manufacturer on March 5, 2003. The airplane’s most recent 100-hour inspection was completed on April 9, 2024. At the time of the inspection, the engine had accrued approximately 2,189.9 hours of operation since the overhaul in 2003. There was no record in the maintenance logbooks of engine oil analysis having been performed.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft

Registration
N4399X
Reported as
Piper PA-28-151
Category
Airplane
Serial number
28-7615006
Built
1975
Airframe hours
7,213
Engine
Lycoming O-360-A4M, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Registered owner
Venture West LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · April 9, 2024 · 60.4 hours before
Departed
P08 · Coolidge, AZ
Destination
KAVQ · Marana, AZ
Airport
P08 · Coolidge Municipal
Equipment
ADS-B, Stall warning system, Electronic primary flight display

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
36
Injuries
None
Certificate
Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
December 18, 2023
Seat
Right
Restraint
3-point
Flight hours
367.4 total · 77.1 in this make and model · 267.8 as pilot in command
Role
Student pilot
Age
36
Injuries
None
Certificate
Student
Medical
Class 1, Without waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
27.9 total · 19.6 in this make and model · 27.9 in the last 90 days · 8.7 in the last 30 days · 1.1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
None
Temperature
88 °F
Altimeter
29.88 inHg
Observed at
P08, 13.5 nm away
METAR
KMZJ 192035Z AUTO 24009G15KT 220V280 10SM -RA CLR 33/M08 A2984 RMK AO2

Docket · 7

The files NTSB released with the investigation on April 1, 2025, on NTSB’s docket system: statements, records, photos and specialists’ reports. 22.3 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.