# NTSB ATL04LA187: Piper PA-22-108, N4647Z, Inverness, FL, September 16, 2004 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 16, 2004, 18:48 local (22:48 UTC) - Place: Inverness, FL - Coordinates: 28.80861, -82.31639 - Nearby events: https://openairdocs.org/map.md?lat=28.8086&lon=-82.3164&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report July 7, 2005 - Report: Approved by Office Director - Parties: Tampa FSDO - 35 - NTSB case key (mKey): 60145 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL04LA187 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60145/pdf - Page: https://openairdocs.org/ntsb/ATL04LA187 ## Probable cause The improper installation of the carburetor which resulted in a loss of engine power and subsequent collision with trees during an emergency landing. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, takeoff - initial climb - maintenance,installation - improper, unknown (cause) - fuel system,carburetor - loose part/bolt/nut/clamp/etc (cause) - Forced landing, emergency descent/landing - In flight collision with object, emergency descent/landing - terrain condition - none suitable - object - tree(s) ## Analysis During climbout about 300 feet above the ground, the airplane's engine lost power down to 2000 rpm. The student pilot reported it audibly "lost a cylinder." He stated the EGT showed very hot on the No. 3 cylinder. He stated he verified the mixture was at full rich, and he reduced throttle a little, but the EGT did not improve. He stated he returned to full throttle and almost immediately the "engine stopped hard" within two seconds, and the airframe shook heavily. He glided the airplane toward a road, and the airplane collided with trees and the ground. Examination of the engine revealed compression developed on all four cylinders when the crankshaft was rotated at the propeller flange. Valve train continuity was observed, and both magnetos produced spark on all towers. The air intake box displayed crush damage. The lower engine cowling was removed, and the carburetor was found separated from the intake manifold. The manifold mount studs displayed chafing, one manifold mount stud was bent. One mounting nut and two flat washers were found in the cowling, and the other mounting nuts were not located. ## Factual narrative On September 16, 2004, about 1848 eastern daylight time, a Piper PA-22-108, N4647Z, registered to and operated by the student pilot, collided with trees and the ground following a loss of engine power shortly after takeoff from Inverness, Florida. The personal flight was operated under the provisions of Title 14 CFR Part 91 with no flight plan filed. Visual meteorological conditions prevailed. The student pilot reported no injuries, and the airplane sustained substantial damage. The local flight departed Inverness, Florida, about 1846 on September 16, 2004. The student pilot stated he departed the airport to the south. He stated that, during climbout about 300 feet above the ground, the airplane's engine lost power down to 2000 rpm, and audibly "lost a cylinder." He stated the EGT showed very hot on the No. 3 cylinder. He stated he verified the mixture was at full rich, and he reduced throttle a little, but the EGT did not improve. He stated he returned to full throttle and "almost immediately, the engine stopped hard, 1800 rpm to 0 rpm in 1 - 2 seconds" and shook the airframe "heavily." He stated he glided the airplane toward a dirt road, and the airplane collided with trees about 50 feet short of the road and came to rest on the ground about 20 feet from the road. Examination of the airplane revealed damage to the wings, wing struts, landing gear, and horizontal stabilizer. Fuel was observed leaking from the wing tanks. Examination of the engine revealed compression developed on all four cylinders when the crankshaft was rotated at the propeller flange. Valve train continuity was observed, and both magnetos produced spark on all towers. The air intake box displayed crush damage. The lower engine cowling was removed, and the carburetor was found separated from the intake manifold. The manifold mount studs displayed chafing, one manifold mount stud was bent. One mounting nut and two flat washers were found in the cowling, and the other mounting nuts were not located. Examination of the maintenance records for the airplane revealed an annual inspection was completed on March 24, 2004. The engine had accumulated 46.4 hours since inspection, and the owner stated he did not know who last handled the carburetor. At the time of the accident, the engine had accumulated 655.9 hours since major overhaul; the engine overhaul was completed June 11, 1977. According to Lycoming Service Instruction 1009AR, the recommended time between overhaul periods (TBO) for the O-235-C1B engine is 2400 hours, or, "in the twelfth year," whichever occurs first. ## Aircraft - Registration: [N4647Z](https://openairdocs.org/deregistered/N4647Z-2012-12-11), registration cancelled 2012-12-11, S/N 22-8169, built 1961 (OpenAirDocs) - Reported make and model: Piper PA-22-108 - Registry model: [Piper PA-22-108](https://openairdocs.org/model/piper-pa-22-108) (registry code 7102204) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 22-8169 - Airframe hours: 2376.3 - Engines: Lycoming O-235-C1B 108 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Albert James Verka - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 24, 2004, 46.4 hours before - Departed: KX40, Inverness, FL - Airport: KX40, Inverness, runway 19, 3,762 × 60 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: none; student; medical: class 3, with waivers/limitations; seat: left; flight hours: 81 total, 65 in this make and model, 38 as pilot in command, 23 in the last 90 days, 3 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 88 °F, dew point 70 °F - Altimeter: 29.88 inHg - Observed at: KOCF, 22 nm away ## 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 20040916031149A](https://openairdocs.org/incident/20040916031149A), Sep 16, 2004: Piper PA22108, Inverness, FL, Substantial damage. (-23) On September 16, 2004, at approximately 1640 EST, a Piper PA-22-108, N4647Z, registered to the pilot [privacy data omitted] impacted the ground after… 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.