# NTSB CEN12IA377: Piper PA-28R-200, N4350T, Lacon, IL, June 18, 2012 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: June 18, 2012, 10:45 local (15:45 UTC) - Place: Lacon, IL - Coordinates: 41.01889, -89.385833 - Nearby events: https://openairdocs.org/map.md?lat=41.0189&lon=-89.3858&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Aircraft structural failure](https://openairdocs.org/ntsb-events/337) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report July 30, 2014 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA-Springfield FSDO - NTSB case key (mKey): 84008 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN12IA377 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/84008/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=84008 - Page: https://openairdocs.org/ntsb/CEN12IA377 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Propeller system: propeller blade section](https://openairdocs.org/ntsb-findings/01046111): Aircraft › Aircraft propeller/rotor · Fatigue/wear/corrosion (probable cause); cases with it: [Piper PA-28R-200, 1 case](https://openairdocs.org/ntsb-findings/01046111/cases.md?model=7102811), [All aircraft, 51 cases](https://openairdocs.org/ntsb-findings/01046111/cases.md) - [Propeller system: propeller blade section](https://openairdocs.org/ntsb-findings/01046111): Aircraft › Aircraft propeller/rotor · Damaged/degraded (probable cause); cases with it: [Piper PA-28R-200, 1 case](https://openairdocs.org/ntsb-findings/01046111/cases.md?model=7102811), [All aircraft, 51 cases](https://openairdocs.org/ntsb-findings/01046111/cases.md) - [Propeller system: propeller indicating system](https://openairdocs.org/ntsb-findings/01046140): Aircraft › Aircraft propeller/rotor · Damaged/degraded; cases with it: [Piper PA-28R-200, 1 case](https://openairdocs.org/ntsb-findings/01046140/cases.md?model=7102811), [All aircraft, 1 case](https://openairdocs.org/ntsb-findings/01046140/cases.md) - [Propeller system: propeller indicating system](https://openairdocs.org/ntsb-findings/01046140): Aircraft › Aircraft propeller/rotor · Not serviced/maintained; cases with it: [Piper PA-28R-200, 1 case](https://openairdocs.org/ntsb-findings/01046140/cases.md?model=7102811), [All aircraft, 1 case](https://openairdocs.org/ntsb-findings/01046140/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Aircraft structural failure](https://openairdocs.org/ntsb-events/337) (defining event); cases with it: [Piper PA-28R-200, 3 cases](https://openairdocs.org/ntsb-events/337/sequence.md?model=7102811), [All aircraft, 290 cases](https://openairdocs.org/ntsb-events/337/sequence.md) ## 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](https://openairdocs.org/aircraft/N4350T), registered now, S/N 28R-7235014, built 1971 (OpenAirDocs) - Reported make and model: PIPER PA-28R-200 - Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7235014 - Year built: 1971 - Airframe hours: 5697 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 42; injuries: none; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Incident 20120618011059I](https://openairdocs.org/incident/20120618011059I), Jun 18, 2012: Piper PA-28R-200, Lacon, IL, Minor damage. While tracking the BDF-300 radial inbound at 4,500' MSL at approximately 5-10 NM east of bdf, the aircraft suddenly began vibrating abnormally. The pilot… ## Docket (8 files) The files NTSB released with the investigation on June 26, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=84008. 7.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413662&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - N4350T Prop Tip Liberation (item 2, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413663&FileExtension=.PDF&FileName=N4350T%20Prop%20Tip%20Liberation-Master.PDF - Materials Laboratory 15 - Factual Report 12-084 (item 3, .PDF, 8 photos, 954 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375253&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report%2012-084-Master.PDF - Test Results from Metro Aircraft Instruments (item 4, .PDF, 226 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413664&FileExtension=.PDF&FileName=Test%20Results%20from%20Metro%20Aircraft%20Instruments-Master.PDF - FAA SAIB Prop Restrictions (item 5, .PDF, 194 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413665&FileExtension=.PDF&FileName=FAA%20SAIB%20Prop%20Restrictions-Master.PDF - Wreckage Release (item 6, .PDF, 449 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413666&FileExtension=.PDF&FileName=Wreckage%20Release-Redacted.PDF - Photo 1. Tachometer in box (item 7, .PDF, 266 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413667&FileExtension=.PDF&FileName=Photo%201.%20Tachometer%20in%20box-Master.PDF - Photo 2. Tachometer on table (item 8, .PDF, 271 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413668&FileExtension=.PDF&FileName=Photo%202.%20Tachometer%20on%20table-Master.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.