# NTSB CEN10LA259: Piper PA32R, N6911Z, Alpine, TX, May 18, 2010 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: May 18, 2010, 09:00 local (14:00 UTC) - Place: Alpine, TX - Coordinates: 30.37111, -103.685836 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.3711&lon=-103.6858&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report December 20, 2010 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Lubbock FSDO - NTSB case key (mKey): 76044 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN10LA259 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/76044/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=76044 - Page: https://openairdocs.org/ntsb/CEN10LA259 ## Probable cause improper installation of the flexible hose and two clamps that connect the intercooler to the turbocharger. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-32R-301T, 2 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=7103220), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Piper PA-32R-301T, 3 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7103220), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) ## Analysis The pilot reported that he performed an engine run-up prior to departure and everything was normal. He then advanced the throttle, prop control, and mixture from left to right and monitored the ehxhaust gas temperature (EGT) to make sure the temperature stayed in the high 1300-degree to low 1400-degree range during the takeoff roll. However, on this takeoff roll he noted that the EGT was reading 1450 degrees so he increased mixture to lower the temperature. Everything seemed to normalize until he became airborne and the engine spooled back. The pilot noted that the EGT was still high at 1440 degrees, so he attempted to land on the remaining stretch of runway. There was not enough room and the airplane exited the runway and collided with a deer fence. Examination of the engine revealed that the flexible hose and two clamps that connect the intercooler to the turbocharger inlet were not installed properly, which caused the flexible hose to slide out of position. The engine had been overhauled in 2007 and installed back on the airplane using the same propeller and accessories. There were no entries between the time the engine was installed to the date of the accident that indicated that either the turbocharger or the intercooler had been worked on. The last annual inspection was performed exactly one year prior to the accident. ## Factual narrative On May 18, 2010, approximately 0900 central daylight time, N6911Z, a Piper PA-32R-301T single-engine airplane, sustained substantial damage when it collided with a fence during a loss of engine power on take off from Alpine-Casparis Municipal Airport (E38), Alpine, Texas. The private pilot and the passenger were not injured. The airplane was registered to and operated by the pilot. No flight plan was filed for the flight that was destined for Fort Stockton, Texas. Visual meteorological conditions prevailed for the personal flight conducted under Title 14 Code of Federal Regulations Part 91. In a written statement, the pilot said that on the morning of the accident he started his airplane and taxied to the fuel pump, then shut down the engine, and topped off both wing tanks with 100LL aviation gasoline. He then re-started the engine and taxied to Runway 19 and performed an engine run-up. The pilot added that he normally advances the throttle, prop control, and mixture from left to right and will monitor the EGT to make sure the temperature stays in the high 1300 degree to low 1400 degree range during the take off roll. However, on this take off roll, he noted the EGT was reading 1450 degrees, so he increased mixture to lower the temperature. The pilot said, the roll out "seemed as I expected since there was no winds and the runway gradient was uphill." The pilot said he rotated around the mid-point of the 6,003-foot-long runway and began to climb but, the "engine seemed to be slowing." He checked the position of the throttle, the prop control, and the mixture, and noted that the EGT was 1440 degrees. The pilot became concerned about the EGT rating and that the engine "seemed to be spooling down" so he attempted to land the airplane. With the gear still extended, the airplane landed on the end of the runway, then went off the runway and collided with a woven deer fence before it came to a stop. A review of photographs taken by the Texas Department of Public Safety revealed that the landing gear had collapsed, the right wing was displaced upwards and a portion of the leading edge was torn away from the wing. The engine was examined on June 21, 2010, under the supervision of the Investigator-in-Charge and representatives from Lycoming engines and Piper Aircraft Incorporated. The engine was manually rotated via the propeller and compression and valve train continuity was established on each cylinder. Spark was produced to all ignition leads as well. The top spark plugs were removed and appeared dark in color. The examination also revealed that the flexible hose and two clamps that connect the intercooler to the turbocharger outlet were not installed properly, which caused the flexible hose to slide out of position. This would have resulted in a higher EGT reading and "spooling down" of the engine as described by the pilot. A review of the maintenance logbooks indicated that the engine had been overhauled in January 2007, and was installed on theairplane in February 2007, using the same propeller and accessories. There were no entries made after the engine was installed regarding maintenance to either the intercooler or the turbocharger. The last annual inspection was conducted on May 18, 2009. The pilot held a private pilot certificate for airplane single and multi-engine land, and instrument airplane. He reported a total of 2,506 hours; of which, 263 hours were in the same make and model airplane. His last Federal Aviation Administration (FAA) third class medical certificate was issued on July 24, 2008. ## Aircraft - Registration: [N6911Z](https://openairdocs.org/deregistered/N6911Z-2013-03-18), registration cancelled 2013-03-18, S/N 32R-8529015, built 1985 (OpenAirDocs) - Reported make and model: PIPER PA32R (301T) - Registry model: [Piper PA-32R-301T](https://openairdocs.org/model/piper-pa-32r-301t) (registry code 7103220) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 32R-8529015 - Airframe hours: 4083 - Engines: LYCOMING TIO540-S1AD 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 19, 2009, 175 hours before - Departed: E38, Alpine, TX - Destination: FST, Fort Stockton, TX - Airport: E38, Alpine-Casparis Municipal, runway 19, 6,003 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: none; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review May 20, 2009; seat: left; flight hours: 2,506 total, 263 in this make and model, 2,431 as pilot in command, 50 in the last 90 days, 36 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 7 knots - Visibility: 10 statute miles - Temperature: 70 °F, dew point 57 °F - Altimeter: 30.11 inHg - Observed at: E38 ## 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 20100518035399A](https://openairdocs.org/incident/20100518035399A), May 18, 2010: Piper PA-32R-301T, Alpine, TX, Substantial damage. On may 18, 2010, at approximately 0900 CDT, the pilot of N6911Z, a Piper saratoga, initiated a take off roll from runway 19 at Alpine Casparis municipal… ## Docket (2 files) The files NTSB released with the investigation on July 27, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=76044. 414 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 360 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330275&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Passenger Statement (item 2, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330276&FileExtension=.PDF&FileName=Passenger%20Statement-Redacted.PDF 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.