# NTSB ATL90FA071: Piper PA-28-151, N991DB, Creola, AL, March 4, 1990

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Field investigation · Final report
- Date: March 4, 1990, 11:19 local (17:19 UTC)
- Place: Creola, AL
- Coordinates: 30.88944, -87.999267 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=30.8894&lon=-87.9993&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: Serious injuries
- Injuries: 2 serious
- Status: Completed, report September 4, 1992
- Report: Approved by Office Director
- NTSB case key (mKey): 8114
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL90FA071
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8114/pdf
- Page: https://openairdocs.org/ntsb/ATL90FA071

## Probable cause

THE PILOT'S FAILURE TO ASSURE THAT PROPER MAINTENANCE AND INSPECTION OF THE AIRCRAFT WERE COMPLETED BEFORE FLIGHT.

## 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, takeoff - initial climb
  - engine assembly,valve,exhaust - failure,total (contributing factor)
  - maintenance,major repair - inadequate (cause)
  - maintenance,installation - inadequate, pilot in command (cause)
  - aircraft preflight - inadequate, pilot in command (cause)
- Forced landing, descent - emergency
- In flight collision with terrain/water, landing

## Analysis

THE PRIVATE PILOT WAS TEST FLYING AN AIRPLANE FOLLOWING A NUMBER THREE CYLINDER CHANGE. ON INITIAL CLIMB, THE ENGINE BEGAN TO VIBRATE, BACKFIRE AND LOSE POWER. THE AIRPLANE CRASHED ON A HIGHWAY MEDIAN LOCATED ABOUT ONE MILE FROM THE AIRPORT CENTER. A POST-CRASH INSPECTION OF THE ENGINE REVEALED A PIECE OF EXHAUST VALVE LODGED IN THE NUMBER ONE PISTON HEAD. ANOTHER VALVE FRAGMENT WAS FOUND INSIDE THE MUFFLER. THE PILOT REPORTED THAT THE NUMBER THREE CYLINDER CHANGE WAS THE RESULT OF A PREVIOUSLY FAILED NUMBER THREE EXHAUST VALVE AND SUBSEQUENT INTERNAL DAMAGE TO THE NUMBER THREE CYLINDER. AN ASSUMPTION WAS MADE THAT THE FRAGMENTS FROM THE FAILED VALVE HAD EXITED THE ENGINE VIA THE EXHAUST SYSTEM. A LOCAL MECHANIC CHANGED THE CYLINDER, BUT DID NOT COMPLETE THE REPAIR DUE TO A LACK OF TIME. THE PILOT FINISHED THE REPAIR, TEST RAN THE ENGINE, AND FLEW THE AIRPLANE ON THE ACCIDENT FLIGHT. THE ENGINE WAS NOT CERTIFIED AIRWORTHY PRIOR TO THE FLIGHT.

## Aircraft

- Registration: [N991DB](https://openairdocs.org/deregistered/N991DB-1992-01-30), registration cancelled 1992-01-30, S/N 28-7615424, built 1976 (OpenAirDocs)
- Reported make and model: PIPER PA-28-151
- Registry model: [Piper PA-28-151](https://openairdocs.org/model/piper-pa-28-151) (registry code 7102805) (OpenAirDocs)
- Category: Airplane
- Serial number: 28-7615424
- Airframe hours: 4356
- Engines: LYCOMING O-320-E3D 150 horsepower reciprocating
- Damage: Substantial damage
- Flight: Part 91
- Registered owner: W. D. Burnham
- Airworthiness certificate: Standard, Normal
- Last inspection: 100 hour, February 28, 1990, 14 hours before

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 39; private; airplane ratings: single-engine land; medical: class 3, expired; seat: left; flight hours: 108 total, 20 in this make and model, 83 as pilot in command, 9 in the last 90 days, 5 in the last 30 days, 1 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 360° at 7 knots
- Visibility: 15 statute miles
- Lowest ceiling: none
- Temperature: 64 °F
- Altimeter: 30.00 inHg
- Observed at: MOB, 18 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 19900304003139A](https://openairdocs.org/incident/19900304003139A), Mar 4, 1990: Piper PA28151, Creola, AL, Substantial damage. Had cylinder replaced due to broken valve. Engine quit on test flight. Stalled landing. Valve piece damaged 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.

---
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.