- Date
- May 14, 2013, 10:50 local (15:50 UTC)
- Place
- Galena, KS
- Injuries
- 1 minor
- Damage
- Substantial damage
- Phase of flight
- Enroute
- Aircraft
- N57719Piper PA-36-285
- Defining event
- Enroute-cruise: Powerplant sys/comp malf/fail
- Weather
- Visual (VMC) · Day
- Status
- Completed · report March 13, 2014
- Report
- Approved by Office Director
- NTSB office
- Central Region
- Parties
- FAA FSDO
- FAA report
- 20130514012409A
- Case key
- 86906
From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.
On this page
Probable cause
The loss of engine power due to improper maintenance by an unknown individual that led to the degradation and deterioration of the No. 2 piston, which was undetected because of overdue maintenance.
Findings · 2
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.
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
Shortly after takeoff, the pilot noticed a decrease in the engine's oil pressure. The engine then sustained a total loss of power, and the airplane collided with terrain during the forced landing. An examination of the engine revealed that the No. 2 piston had failed. In addition, each of the spark plugs had two washers installed, instead of one, and the oil filter contained many metal particles. The two washers likely altered the detonation characteristics of the pistons, causing them to overheat. As the No. 2 piston degraded, metal particles collected in the oil filter. Maintenance records indicate that the engine was overdue for a recommended oil change; the deteriorating piston would likely have been detected during an oil change. The mechanic who performed the last annual inspection was not aware that additional spark plug washers had been installed on the engine.
Factual narrative
On May 14, 2013, about 1050 central daylight time, a Piper PA-36-285 airplane, N57719, conducted a forced landing near Galena, Kansas. The commercial pilot sustained minor injuries. The airplane sustained substantial damage to the fuselage. The airplane was registered to and operated by Four States Sky Ag Inc. under the provisions of 14 Code of Federal Regulations Part 137 as an agricultural application flight. Visual meteorological conditions prevailed for the flight, which operated without a flight plan. The local flight departed the Swalley Airpark (78KS), Baxter Springs, Kansas, about 1045. According to a statement provided by the pilot to the responding Federal Aviation Administration (FAA) inspectors, the airplane had departed 78KS and he had just began to level off when he noticed a decrease in oil pressure. The engine experienced a total loss of power before the pilot could set up for a forced landing. The airplane collided with terrain in an open field. An examination of the engine conducted by the FAA inspectors revealed that the number 2 cylinder piston had failed. A large amount of aluminum particles were observed in the oil and the oil filter. Each spark plug had two spark plug washers. Maintenance records determined that the recommended oil change time had been exceeded. The mechanic that performed the last annual inspection stated he had not installed the extra spark plug washers and was not aware of their presence on the engine. It could not be determined who installed the additional spark plug washers.
Aircraft
- Registration
- N57719
- Reported as
- Piper PA-36-285
- Category
- Airplane
- Serial number
- 36-7660041
- Airframe hours
- 2,958.8
- Engine
- Cont Motor 6-285-A, 285 horsepower, reciprocating
- Damage
- Substantial damage
- Flight
- Aerial application · Part 137
- Operator
- Four States Sky Ag Inc, doing business as Four States Sky Ag LLC
- Registered owner
- Four States Sky Ag Inc
- Airworthiness certificate
- Special, Restricted (Special)
- Last inspection
- Annual · January 24, 2013 · 176.2 hours before
- Departed
- 78KS · Baxter Springs, KS
- Destination
- 78KS · Baxter Springs, KS
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
- 48
- Injuries
- Minor
- Certificate
- Commercial
- Airplane ratings
- Single-engine land
- Medical
- Class 2, Without waivers/limitations
- Seat
- Single
- Restraint
- 4-point
Weather
- Conditions
- Visual (VMC) · Day
- Wind
- 220° at 14 knots, gusting 22
- Visibility
- 10 statute miles
- Lowest ceiling
- None
- Temperature
- 79 °F, dew point 52 °F
- Altimeter
- 30.02 inHg
- Observed at
- KJLN, 9 nm away
Docket · 2
The files NTSB released with the investigation on January 22, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.6 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.