CEN12IA377

NTSB incident investigation · Piper PA-28R-200 · Lacon, IL · June 18, 2012

Incident · No injuriesIncident investigationFinal report
Date
June 18, 2012, 10:45 local (15:45 UTC)
Place
Lacon, IL
Injuries
1 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N4350TPiper PA-28R-200
Defining event
Enroute-cruise: Aircraft structural failure
Weather
Visual (VMC) · Day
Status
Completed · report July 30, 2014
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA-Springfield FSDO
FAA report
20120618011059I
Case key
84008

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

The propeller blade’s failure due to a fatigue crack that originated from a surface gouge that resulted from foreign object damage to the propeller blade that occurred at an unknown time.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Propeller system: propeller blade sectionAircraft › Aircraft propeller/rotor · Fatigue/wear/corrosionPiper PA-28R-200: 1 caseAll aircraft: 51 casesProbable cause
Propeller system: propeller blade sectionAircraft › Aircraft propeller/rotor · Damaged/degradedPiper PA-28R-200: 1 caseAll aircraft: 51 casesProbable cause
Propeller system: propeller indicating systemAircraft › Aircraft propeller/rotor · Not serviced/maintainedPiper PA-28R-200: 1 caseAll aircraft: 1 case

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported that he was flying the airplane at 4,500 feet mean sea level with 23 inches of manifold pressure and with the engine at 2,350 to 2,400 rpm when the airplane began to abnormally vibrate. He scanned the instruments and observed no other abnormal indications. He executed an emergency landing to an airport without incident. The examination of the airplane revealed that about 6 inches of a propeller blade tip had separated from the propeller. The metallurgical examination of the fracture surface revealed that a fatigue crack had originated about 0.06 inch from the blade's leading edge. A surface gouge was found at the origin of the fatigue crack, which indicated that the direction of the damage was from the leading to trailing edge consistent with foreign object impact to a rotating propeller. A test of the airplane's tachometer revealed that it was indicating 50 rpm higher than the actual propeller rpm and that it had a restricted propeller operating range from 2,100 to 2,350 rpm. When the pilot set the propeller to 2,350 or 2,400 rpm using the airplane's tachometer, the actual rpm would have been operating within the restricted rpm range.

Factual narrative

On June 18, 2012, at 1045 central daylight time, a Piper PA-28R-200, N4350T, experienced a violent vibration during cruise flight. The private pilot executed a precautionary landing at the Marshall County Airport (C75), Lacon, Illinois. The pilot was not injured. The airplane was registered to and operated by the Marshall County Flying Club under the provisions of the 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the incident, and no flight plan was filed. The airplane departed C75 at 1008 on a local flight. The pilot reported that he was flying at 4,500 feet above mean sea level with 23 inches of manifold pressure and 2,350 to 2,400 rpm when the airplane began to abnormally vibrate. He scanned the instruments and determined there were no other abnormal indications. He began a left turn direct to C75 which was about 8 nautical miles away. He made a straight in approach to runway 10 and landed without incident. An inspection of the airplane revealed that about 6 inches of a propeller blade tip had separated from the propeller. The remaining propeller blade was sent to the National Transportation Safety Board's Materials laboratory for examination. The examination revealed that the fracture surface was about 30 ¼ inches from the butt of the propeller. About 70 percent of the fracture surface had a reflective luster and was relatively flat, indicative of a fatigue crack growth region. The remaining area had a rough matte surface, indicative of a final overstress failure. The origin of the fatigue crack was located on the flat side of the blade, about 0.06 inches from the leading edge of the blade. There was a surface gouge at the origin of the fatigue crack which was about 0.02 inches long chordwise, and about 0.0016 inches deep. The scratch marks within the gouge suggest that the direction of damage was from the leading to trailing edge, which is consistent with foreign object impact to a rotating propeller. The airplane's maintenance records indicated that a new Hartzell propeller, model HC-C2YK-1BF, was installed on the airplane on May 29, 2007. At the time of the incident, the propeller had accumulated 592.3 hours since new. The last annual inspection of the propeller occurred on February 5, 2012, at a time of 530.3 hours. At the time of the incident, the airplane had flown 62 hours since the annual inspection. The airplane's tachometer indicated that the maximum rpm was 2,700 rpm. The tachometer indicated that there was a restricted propeller range from 2,100 to 2,350 rpm. The Federal Aviation Administration (FAA) issued a Special Airworthiness Information Bulletin (SAIB) concerning "Propeller RPM Restrictions and Placards" on May 14, 2008. The SAIB stated the following information: "This Special Airworthiness Information Bulletin (SAIB) alerts you, owners, operators, pilots, mechanics, and certificated repair facilities of the potential for propeller failures on pistonengine aircraft due to prolonged operation in a restricted RPM (revolutions per minute) range as a result of inaccurate tachometers, missing or improper tachometer markings, or missing or improper instrument panel placards… Propeller manufacturers determine a propeller's operating vibratory stresses during certification. RPM zones of localized high vibratory stress are a relatively common finding during testing. If a zone of localized high vibratory stress occurs within the propeller operating range, then the propeller may be approved with the addition of an operating restriction, placard, or life limit... Failure to comply with tachometer markings and instrument panel placards could result in prolonged operation within a restricted RPM range and increase the potential for a propeller failure. Mechanical tachometers do not necessarily retain their accuracy for the life of the aircraft. Reports of tachometer errors of 50 RPM are common. Errors of 150 to 250 RPM have been reported. Using an inaccurate tachometer could result in a restricted RPM range or maximum RPM red line being unknowingly violated by the pilot, which could result in repetitive or prolonged exposure to damaging propeller stresses. The most common failure associated with this condition is a blade tip separation that results from a fatigue crack, but failure of the propeller hub and/ or blade retention feature can also occur. Prolonged operation within a restricted RPM range, or above the maximum RPM, will be further aggravated by the presence of surface conditions such as nicks or corrosion pits." The tachometer was sent to an avionics facility for testing. The results using a digital testing device indicated the following: Tachometer Indication Instrument Reading 500 rpm 500 rpm 1,000 rpm 1,000 rpm 1,500 rpm 1,500 rpm 2,000 rpm 2,050 rpm 2,100 rpm 2,150 rpm 2,200 rpm 2,250 rpm 2,300 rpm 2,350 rpm 2,400 rpm 2,475 rpm 2,500 rpm 2,575 rpm 2,700 rpm 2,775 rpm

Aircraft

Registration
N4350T
Reported as
Piper PA-28R-200
Category
Airplane
Serial number
28R-7235014
Built
1971
Airframe hours
5,697
Engine
Lycoming IO-360-C1C, 180 horsepower, reciprocating
Damage
Minor damage
Flight
Personal · Part 91
Operator
Marshall County Flying Club Inc
Registered owner
Marshall County Flying Club Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 5, 2012
Departed
C75 · Lacon, IL
Destination
C75 · Lacon, IL
Airport
C75 · Marshall County Airport, runway 31, 3,200 × 75 ft, asphalt
Equipment
Stall warning system

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
42
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2
Last flight review
July 1, 2011
Seat
Left
Flight hours
1,250 total · 19 in this make and model · 8 in the last 90 days · 4 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 17 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 70 °F
Altimeter
29.82 inHg
Observed at
BMI, 38 nm away

Docket · 8

The files NTSB released with the investigation on June 26, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.6 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.