# NTSB BFO94LA038: Piper PA-32R-300, N38780, Norfolk, VA, February 7, 1994 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: February 7, 1994, 16:00 local (21:00 UTC) - Place: Norfolk, VA - Coordinates: 36.909854, -76.329895 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.9099&lon=-76.3299&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 6 uninjured - Status: Completed, report April 5, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 8888 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=BFO94LA038 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8888/pdf - Page: https://openairdocs.org/ntsb/BFO94LA038 ## Probable cause FATIGUE FAILURE OF THE ENGINE MOUNTING BOLT WHICH RESULTED IN LOSS OF ENGINE POWER AND SUBSEQUENT ON GROUND COLLISION WITH THE TERRAIN. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, cruise - engine installation,mounting bolt - fatigue (cause) - Forced landing, descent - emergency - Hard landing, landing - flare/touchdown - terrain condition - grass - Gear collapsed, landing - flare/touchdown - landing gear - overload ## Analysis THE FLIGHT WAS CRUISING AT 7500' WHEN THE ENGINE STARTED TO RUN ROUGH 12.2 NAUTICAL MILES FROM NORFOLK AIRPORT. THE PILOT STATED THAT HE DID NOT CHANGE THE PROPELLER SETTING UNTIL HE WAS OVERHEAD THE AIRPORT. THEREAFTER THERE WAS A LOUD EXPLOSION AND THE OIL ACCESS DOOR BLEW OPEN AND PIECES OF THE ENGINE EXITED THE AIRPLANE. DURING THE FORCED LANDING ON RUNWAY 23 THE AIRPLANE TOUCHED DOWN ON THE GRASSY AREA. EXAMINATION REVEALED THE NO. 2 CYLINDER ASSEMBLY, PISTON AND CONNECTING ROD SEPARATED FROM THE CRANKCASE AT THE CYLINDER HOLD-DOWN STUD AREA. FOR METALLURGICAL EXAMINATION THE HOLD- DOWN STUDS ALONG WITH THE CRANKCASE WERE SENT TO THE NTSB LAB IN WASHINGTON, DC. THE EXAMINATION DISCLOSED FATIGUE CRACKS AND THERE WAS EVIDENCE OF WELDING THROUGH THE CRANKCASE. THE WELDING AREAS WERE SOFTER THAN THE AREAS THAT WERE NOT WELDED. ## Factual narrative On Monday, February 7, 1994, at 1600 eastern standard time, a Piper PA-32R-300, N38780, collided with the ground following a power-off forced landing at Norfolk International Airport, Norfolk, Virginia. The certificated flight instructor, and his five passengers were not injured while the airplane sustained substantial damage. The airplane was being operated under 14 CFR 91. The flight originated in Greenville, North Carolina. The intended destination was Hartford, Connecticut. Visual meteorological conditions prevailed and a flight plan was not filed. The pilot stated that he and his five passengers were at a cruising altitude of 7500 feet MSL when, "the engine changed vibration and ran somewhat rough." He stated that he took the controls from the student and declared an emergency with Norfolk Approach as he was 12.2 nautical miles from Norfolk Airport. The pilot stated that he advised Norfolk Approach that he would try to maintain his current altitude and try to correct the problem. The pilot stated that enroute to the airport he did not change any of the power settings until he was directly overhead the airport. He stated that he increased the propeller rpm slowly, and shortly thereafter he heard a loud explosion coming from under the left side of the engine cowling. He stated that the oil access door blew open, and pieces of the engine exited the aircraft. The pilot stated that he shut the engine down by turning off the magnetos and made a forced landing at Norfolk Airport. During the forced landing on runway 23, the airplane touched down west of the runway in a grassy area. The airplane was examined at the accident site by the FAA. The examination revealed oil on the windshield of the airplane, and the number 2 cylinder along with its respective piston and connecting rod had exited the engine through the engine cowling. The engine was removed from the airplane and shipped to Piedmont Aviation Services Inc., of Winston-Salem, North Carolina, for examination. The examination confirmed the number 2 cylinder was missing from the crankcase and the attaching studs and thru bolts were fractured. The breakaway torque was checked on all cylinder studs and thru bolts which were not affected by the cylinder separation. The values for each are listed on the attached two tables. The remaining hold down stud bolts along with the crankcase were sent to the NTSB Lab in Washington, DC, for metallurgical examination. The examination revealed that the separation of the six hold down studs and two through bolts for the number two cylinder were the result of fatigue cracks that emanated along multiple sites at the root of the threads. Metallographic section through the pad for one of the hold down studs for the number 2 cylinder revealed that extensive weld repair had been performed through the entire thickness of the case at this location. Hardness measurements on the section cut from the engine case showed that the welded areas were much softer than the areas that were not welded. The investigation revealed that the engine had over 3834 hours of total time, including 343 hours since major overhaul. The last annual inspection was completed on September 20, 1993, and the airplane had accumulated over 160 hours since the last inspection. ## Aircraft - Registration: [N38780](https://openairdocs.org/deregistered/N38780-2012-11-14), registration cancelled 2012-11-14, S/N 32R-7780471, built 1977 (OpenAirDocs) - Reported make and model: PIPER PA-32R-300 - Registry model: [Piper PA-32R-300](https://openairdocs.org/model/piper-pa-32r-300) (registry code 7103213) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 32R-7780471 - Airframe hours: 3791 - Engines: LYCOMING IO-540-K1G5D 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Guardione Vincent & Michael - Registered owner: Vincent A Guardione - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 3, 1994, 50 hours before - Departed: DPL, KENANSVILLE, NC - Destination: HFD, HARTFORD, CT - Airport: ORF, Norfolk International, runway 23, 9,000 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 23; commercial, flight instructor; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: right; flight hours: 305 total, 24 in this make and model, 182 as pilot in command, 26 in the last 90 days, 23 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 110° at 9 knots - Visibility: 20 statute miles - Lowest ceiling: none - Temperature: 54 °F, dew point 23 °F - Altimeter: 30.00 inHg - Observed at: ORF ## 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 19940207001589A](https://openairdocs.org/incident/19940207001589A), Feb 7, 1994: Piper PA32R300, Norfolk, VA, Substantial damage. Rough runing engine, engine blew cylinder over airport. Overshot runway. Improper weld at cylinder base. 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.