# NTSB ATL89FA078: Piper PA-28-140, N8456R, Bagley, AL, January 18, 1989

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: January 18, 1989, 08:30 local (14:30 UTC)
- Place: Bagley, AL
- Coordinates: 33.709144, -86.969787 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=33.7091&lon=-86.9698&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 2 fatal, 1 serious
- Status: Completed, report June 18, 1990
- Report: Approved by Office Director
- NTSB case key (mKey): 7874
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL89FA078
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/7874/pdf
- Page: https://openairdocs.org/ntsb/ATL89FA078

## Probable cause

INADEQUATE MAINTENANCE BY OTHER MAINTENANCE PERSONNEL WHICH ALLOWED A FOREIGN OBJECT TO REMAIN IN THE ENGINE AND DAMAGE/SHORT THE SPARK PLUGS IN THE #2 AND #3 CYLINDERS.  TREES IN THE EMERGENCY LANDING AREA CONTRIBUTED TO THE ACCIDENT.  IF SHOULDER HARNESSES HAD BEEN INSTALLED AND USED, INJURY(S) MAY HAVE BEEN LESS SEVERE.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power(partial) - mech failure/malf, cruise - normal
  - maintenance - inadequate, other maintenance personnel (cause)
  - ignition system,spark plug - foreign object damage (cause)
  - ignition system,spark plug - shorted (cause)
- Forced landing, descent - emergency
- In flight collision with object, landing
  - object - tree(s) (contributing factor)
  - misc eqpt/furnishings,shoulder harness - not installed

## Analysis

ACCORDING TO THE SURVIVING PASSENGER, A PARTIAL LOSS OF PWR OCCURRED DRG FLT & THE PLT TRIED TO LAND IN A FIELD, BUT THEFIELD WAS TOO SHORT & THE ACFT HIT TREES & CRASHED. DRG AN EXAM OF THE ENG, A METAL FRAGMENT WAS FND IN THE #3 CYLINDER.EVIDENCE OF FOREIGN OBJECT DMG (PEENING) WAS FND IN THE #2 & #3 COMBUSTION CHAMBERS & ON THEIR RESPECTIVE PISTON FACES. THE RESPECTIVE SPARK PLUGS WERE DMGD TO THE POINT THAT THEIR GROUND ELECTRODES HAD BECOME DISPLACED & SHORTED TO THE CENTER ELECTRODES. A METALLURGICAL EXAM OF THE FRAGMENT REVEALED IT WAS FM A BROKEN EXHAUST VALVE; HOWEVER, EXCEPT FOR PEENING, THE VALVES WERE INTACT. FURTHER INVESTIGATION REVEALED THE ENG HAD AN EXHAUST VALVE FAILURE IN 1980 & HAD FLOWN98 HRS SINCE THEN. PIECES OF THAT VALVE WERE NOT FND & WERE ASSUMED TO HAVE BEEN 'SPIT OUT' THRU THE EXHAUST SYS. DRG ANANNUAL INSPN ON 1/12/89, AN EXHAUST VALVE FRAGMENT WAS FND IN THE ENG MUFFLER. THE OWNER WAS NOTIFIED; THE EXHAUST PIPESWERE REMOVED & INSPECTED; NO OTHER FRAGMENTS WERE FND. THE ACFT WAS NOT EQUIPPED WITH SHOULDER HARNESSES.

## Aircraft

- Registration: [N8456R](https://openairdocs.org/deregistered/N8456R-1992-03-24), registration cancelled 1992-03-24, S/N 2822358 (OpenAirDocs)
- Reported make and model: PIPER PA-28-140
- Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs)
- Category: Airplane
- Serial number: 28-22358
- Airframe hours: 2318
- Engines: LYCOMING O-320-E2A 140 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Operator: Fowler, Andrew O.
- Registered owner: Fowler, A.O.
- Airworthiness certificate: Standard, Utility; Standard, Normal
- Last inspection: Annual, January 12, 1989, 3 hours before
- Departed: 2M6, WALLS, MS
- Destination: EUF, EUFAULA, AL
- Flight plan: VFR

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 58; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 209 total, 21 in this make and model, 166 as pilot in command, 15 in the last 90 days, 8 in the last 30 days, 3 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 200° at 3 knots
- Visibility: 7 statute miles
- Lowest ceiling: none
- Temperature: 50 °F, dew point 30 °F
- Altimeter: 30.00 inHg
- Observed at: BHM, 15 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 19890118000819A](https://openairdocs.org/incident/19890118000819A), Jan 18, 1989: Piper PA28140, Bagley, AL, Substantial damage, 2 fatal. Engine failed. Overshot large open field from 6500 ft AGL into trees and ravine. Valve pieces in engine.

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.

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