ANC97LA055

NTSB accident investigation · Piper PA-32 · Quinhagak, AK · April 12, 1997

Accident · No injuriesLimited investigationFinal report
Date
April 12, 1997, 15:40 local (23:40 UTC)
Place
Quinhagak, AK
Injuries
6 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N9000NPiper PA-32
Weather
Visual (VMC) · Day
Status
Completed · report November 10, 1998
Report
Approved by Office Director
NTSB office
Alaska Regional Office
FAA report
19970412005719A
Case key
2988

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

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Probable cause

A disconnected exhaust manifold collector, improper maintenance of the airplane by company maintenance personnel, and the pilot's poor judgement in electing to initiate another flight after observing smoke in the cockpit.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

FireClimb
Exhaust system,manifold/pipe - disconnectedCause
Maintenance - inadequateOther maintenance personnelCause
Judgment - poorPilot in commandCause
Engine compartment - fire
Forced landingEmergency landing after takeoff

Analysis

The air taxi pilot/company owner was taking off from his base of operations airport in rural Alaska with a new hire pilot and four passengers. About one mile from the airport, the pilot and passengers saw and smelled smoke. The pilot immediately returned and landed. At the pilot's request, the new hire pilot exited the airplane, checked the engine oil dipstick for security, and then reentered the cockpit. The pilot made another takeoff. Shortly after takeoff, smoke began to fill the cockpit, and flame was visible coming from the engine cowling. An emergency landing was made just off the airport on a small island. The occupants of the airplane extinguished the fire with water and a small fire extinguisher. Postaccident inspection disclosed a loose exhaust manifold and fire damage in the vicinity of the exposed exhaust ports. Nuts which affix the exhaust manifold to the engine were found in the bottom of the cowling. The airplane had maintenance performed about one month previously which necessitated the removal of the left manifold.

Factual narrative

On April 12, 1997, about 1540 Alaska daylight time, a wheel equipped Piper PA-32 airplane, N9000N, owned and operated by Kusko Aviation, sustained substantial damage following an engine fire and subsequent forced landing shortly after takeoff from the Quinhagak Airport, Quinhagak, Alaska. The two commercial certificated pilots aboard were not injured; the four passengers aboard have not reported any injuries. The 14 CFR Part 135 on-demand air taxi flight was departing Quinhagak en route to Goodnews, Alaska. The flight operated in visual meteorological conditions. The pilot-in-command was the owner of the company; the second pilot had just been hired, and was along on a familiarization ride.

Information received from the pilot-in-command and one of the passengers, revealed that the airplane departed Quinhagak about 1520. About a mile from the airport, the pilot and passengers noted a small amount of smoke in the cockpit and cabin. The pilot returned and landed. The second pilot checked the oil dip stick for security, and then reentered the cockpit. The pilot elected to takeoff again. Shortly after liftoff, smoke begin to fill the cockpit, and visible flame was observed coming from the engine cowling. The pilot reduced power and made an emergency off airport landing on Willow-covered terrain about 100 yards off the departure end of runway 04.

The occupants exited the airplane, and the fire was extinguished by throwing buckets of water on the engine and using a hand-held fire extinguisher.

FAA inspectors traveled to the accident site on June 18 and inspected the wreckage. They noted that the engine's left exhaust collector was disconnected from the numbers 2,4, and 6, cylinders. The collector was pulled away from the exhaust ports, "allowing open exhaust flame to ignite the intake paper air filter, scat tubing, wiring, and fuel flow meter rubber vent line." The nuts which secure the collector were found in the bottom of the engine cowling. The studs which the nuts screwed onto were observed to be black and sooty. The inspectors noted that maintenance work (gaskets replaced on numbers 4 and 6 cylinders) had been performed on the engine on March 18, 1997. The work performed would have necessitated removing the left exhaust collector.

Aircraft

Registration
N9000N
Reported as
Piper PA-32
Category
Airplane
Serial number
32-40883
Airframe hours
5,291
Engine
Lycoming IO-540-KIA5, 300 horsepower, reciprocating
Damage
Substantial damage
Fire
In-Flight
Flight
Part 135
Registered owner
Kusko Aviation
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · March 18, 1997 · 41 hours before
Departed
AQH
Destination
GNU · Goodnews, AK
Flight plan
Company VFR

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
61
Certificate
Commercial
Airplane ratings
Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
16,000 total · 7,500 in this make and model · 15,850 as pilot in command · 146 in the last 90 days · 49 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
350° at 4 knots
Visibility
60 statute miles
Lowest ceiling
None
Temperature
45 °F

FAA reports on this event · 1

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