CEN13LA280

NTSB accident investigation · Piper PA-36-285 · Galena, KS · May 14, 2013

Accident · Minor injuriesLimited investigationFinal report
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.

MaintenancePersonnel issues › Task performance · OtherPiper PA-36-285: 1 caseAll aircraft: 143 casesProbable cause

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.