# NTSB CEN13LA280: Piper PA-36-285, N57719, Galena, KS, May 14, 2013 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: May 14, 2013, 10:50 local (15:50 UTC) - Place: Galena, KS - Coordinates: 37.068889, -94.664718 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.0689&lon=-94.6647&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report March 13, 2014 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 86906 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN13LA280 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/86906/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=86906 - Page: https://openairdocs.org/ntsb/CEN13LA280 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-36-285, 1 case](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=7103610), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Maintenance](https://openairdocs.org/ntsb-findings/02062000): Personnel issues › Task performance · Other (probable cause); cases with it: [Piper PA-36-285, 1 case](https://openairdocs.org/ntsb-findings/02062000/cases.md?model=7103610), [All aircraft, 143 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Piper PA-36-285, 2 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=7103610), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Piper PA-36-285, 2 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7103610), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-36-285, 8 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103610), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N57719-2021-01-09), registration cancelled 2021-01-09, S/N 36-7660041, built 1975 (OpenAirDocs) - Reported make and model: PIPER PA-36-285 - Registry model: [Piper PA-36-285](https://openairdocs.org/model/piper-pa-36-285) (registry code 7103610) (OpenAirDocs) - Registry engine: [Continental 6-285-A](https://openairdocs.org/engine/continental-6-285-a) (registry code 17038, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 36-7660041 - Airframe hours: 2958.8 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; injuries: minor; 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 ## 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 20130514012409A](https://openairdocs.org/incident/20130514012409A), May 14, 2013: Piper PA-36-285, Galena, KS, Destroyed. After take of from the baxter springs airport (78KS) the pilot leveled off and noticed a drop in oil pressure, in the process of trying to find a place to land… ## Docket (2 files) The files NTSB released with the investigation on January 22, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=86906. 3.6 MB in all. - ROC with FSDO Inspectors (item 1, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407472&FileExtension=.PDF&FileName=ROC%20with%20FSDO%20Inspectors-Master.PDF - Photo 1: Wreckage overview (FAA Photo) (item 2, .PDF, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407473&FileExtension=.PDF&FileName=Photo%201%3A%20Wreckage%20overview%20(FAA%20Photo)-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.