ATL96TA047

NTSB accident investigation · Piper PA-32-300 · Windermere, FL · February 13, 1996

Accident · Minor injuriesFinal report
Date
February 13, 1996, 13:04 local (18:04 UTC)
Place
Windermere, FL
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N8951NPiper PA-32-300
Weather
Visual (VMC) · Day
Status
Completed · report November 11, 1996
Report
Approved by Office Director
FAA report
19960213001679A
Case key
3766

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

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

the use of improper connecting rod bolts, failure of the overhaul facility to record the correct overhaul date on the work orders for the stored connecting rod assemblies, and subsequent failure of the connecting rod bolts.

Analysis

The flight departed Kissimmee, Florida, on a forest fire spotting mission. The engine began to run rough and lost power. The airplane landed in an orange grove, striking a tree. An engine examination revealed that improper connecting rod bolts had been used in the engine. The bolts in two connecting rods failed, resulting in the failure of the engine. Investigation determined that the bolts were manufactured in the '80s and became available in the U.S. market in February 1994. The bolts were obtained by a repair station on June 1994 and installed in connecting rod assemblies that were in storage. The overhaul date on the work order for the stored rod assemblies was not changed at that time, and it continued to indicate an overhaul date of 2/9/94. The stored rod assemblies were then installed in the engine during an overhaul in October 1994. In March 1995, an AD was issued to inspect engines with connecting rod bolts installed on or since 2/15/94. The AD was not complied with on the engine because the repair station certified that the rod assemblies had been overhauled on 2/9/94, before the effective date of the AD.

Factual narrative

On February 13, 1996, about 1304 eastern standard time, a Piper PA-32-300, N8951N, collided with a tree during a forced landing at Windermere, Florida. The aircraft was operated by the Florida Department of Agriculture under the provisions of Title 14 CFR Part 91 and visual flight rules. A flight plan was not filed for the public use flight, and visual meteorological conditions prevailed. The commercial pilot sustained minor injuries; the aircraft was substantially damaged. The aircraft departed Kissimmee Airport, Kissimmee, Florida, at 1100 on the same day.

The pilot stated that while in cruise flight on a forest fire spotting mission, the engine began to run roughly, vibrating the entire aircraft. Oil started spraying from the engine onto the windscreen, then the engine quit. The pilot executed an emergency landing, touching down in an orange grove, and collided with a tree.

An engine examination revealed that bogus connecting rod bolts had been used in the engine. The bolts in two connecting rods failed, resulting in the failure of the engine. Investigation determined that the bolts were manufactured in the 1980s, and became available in the Unites States market on February 15, 1994. The bolts were obtained by the repair station in June, 1994, and installed in connecting rod assemblies that were in storage. The overhaul date on the work order for the stored rod assemblies was not changed at that time, and continued to indicate an overhaul date of February 9, 1994. The stored rod assemblies were then installed in the engine during an overhaul in October 28, 1994. On March 17, 1995, Airworthiness Directive (AD) 95-07-01 was issued to inspect engines with connecting rod bolts installed on or since February 15, 1994. The AD was not complied with on the engine because the repair station certified that the rod assemblies had been overhauled on February 9, 1994, before the effective date of the AD.

The FAA conducted an investigation to locate and remove from the system all defective connecting rod bolts from the original manufacturer.

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.

Loss of engine power(total) - mech failure/malfCruise
Engine assembly,connecting rod bolt - improperCause
Maintenance,overhaul - improperOther maintenance personnelCause
Condition(s)/step(s) in errorOther maintenance personnelCause
Engine assembly,connecting rod bolt - failureCause
Forced landingEmergency descent/landing
On ground/water collision with objectEmergency landing
Object - tree(s)

Aircraft

Registration
N8951N
Reported as
Piper PA-32-300
Category
Airplane
Serial number
32-40753
Airframe hours
3,414
Engine
Lycoming IO-540-K1A5, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Public aircraft · Part 91
Operator
Florida Dept. Of Agriculture
Registered owner
James E. Smith
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 12, 1995 · 33 hours before
Departed
ISM · Kissimmee, FL
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
31
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
1,755 total · 26 in this make and model · 1,715 as pilot in command · 41 in the last 90 days · 26 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
340° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
54 °F, dew point 25 °F
Altimeter
30.00 inHg
Observed at
MCO, 10 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.