CEN14LA058

NTSB accident investigation · Piper PA 28-140 · San Antonio, TX · November 16, 2013

Accident · Serious injuriesLimited investigationFinal report
Date
November 16, 2013, 10:45 local (16:45 UTC)
Place
San Antonio, TX
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N57DBPiper PA 28-140
Defining event
Takeoff: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report December 15, 2014
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration, Piper, Lycoming
FAA report
20131116025749A
Case key
88439

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

A partial loss of engine power after departure due to the collapse of the carburetor air inlet duct, which restricted the airflow to the engine. Contributing to the accident was the overdue annual inspection and the installation of the improper air inlet duct.

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.

Power plant: eng air baffle sec (recip.)Aircraft › Aircraft power plant · FailurePiper PA-28-140: 1 caseAll aircraft: 3 casesProbable cause
Power plant: eng air baffle sec (recip.)Aircraft › Aircraft power plant · Capability exceededPiper PA-28-140: 1 caseAll aircraft: 3 casesProbable cause
Power plant: eng air baffle sec (recip.)Aircraft › Aircraft power plant · Incorrect service/maintenancePiper PA-28-140: 1 caseAll aircraft: 3 casesProbable cause
Maintenance/inspections: scheduled maint checksAircraft › Aircraft handling/service · Not inspectedPiper PA-28-140: 4 casesAll aircraft: 76 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

The pilot reported that, after advancing the airplane's throttle to full power for takeoff, the engine produced "normal thrust," the airspeed reached 60 mph, and the tachometer indicated 2,700 rpm. The acceleration was smooth and all indications were normal when the airplane reached rotation. About 600 feet above the ground, the airplane's nose began to lower, the airspeed remained 60 mph, and the tachometer indicated 2,000 rpm. The pilot pitched the nose down to prevent a stall and ensured that the throttle and mixture controls were full forward and that the electric fuel pump was on. He reported to the air traffic controller that the airplane's engine was not producing sufficient power and that he was returning to the runway. Shortly after the radio transmission, the airplane impacted terrain and a tree. An examination of the airplane's engine revealed a fuel stain on the carburetor inlet, indicating that the airflow through the carburetor had been decreased. The carburetor induction air inlet duct was single-thickness scat-type ducting, which was not the material described for the part, which should have been installed in accordance with a manufacturer's service bulletin. The material appeared to be beyond its normal service life with frayed edges and loose strings, and most of the wire was loose and separated from the duct. Further, the carburetor air inlet duct appeared to have been compressed due to negative air pressure during high engine rpm, which would have restricted the airflow to the engine and reduced the engine power. The No. 2 cylinder and its associated spark plugs contained dark sooting, likely due to the restricted airflow, which resulted in a rich fuel/air mixture inside the cylinder. The airplane was 12 days overdue for an annual inspection; the improper, damaged air duct could have been identified during the inspection.

Factual narrative

Piper Aircraft Service Bulletin (SB) 356 The induction air inlet duct was not of the same material described for Piper Aircraft part number 99849-4, which should have been installed in accordance with Piper Aircraft Service Bulletin (SB) 356, effective September 15, 1972. The purpose of SB 356 was for a more positive inspection and maintenance practices for the induction air inlet duct. Federal Aviation Administration Special Airworthiness Information Bulletin (SAIB) CE-14-23 On August 6, 2014, the Federal Aviation Administration issued Special Airworthiness Information Bulletin (SAIB) CE-14-23. The SAIB recommended to owners, operators and maintenance personnel or Piper Models PA-28 and others, that the air inlet duct be inspected within the next 25 hours to verify that it is an approver Piper part and does not exhibit any of the following conditions: 1. Broken or loose cords on external surface, 2. Loose or displaced supporting wire, or 3. Signs of wear, perforation, deterioration or collapse. If the duct exhibits any of the conditions or is not an approved Piper part, then it must be replaced with an approved Piper part before the next flight. Engine Data Monitor Card The airplane contained an engine data monitoring card which did not contain information pertaining to the accident flight. The Piper PA 28-140, was a four place, low-wing, single engine, airplane which was manufactured in 1969. The airplane was powered by a 150-horsepower Lycoming O-320-E2A engine which drove a two-blade, metal Sensenich propeller. On November 4, 2012, at an airplane total time of 3829.82 hours, an annual inspection was completed with no anomalies noted. The airplane was 12 days overdue for an annual inspection. On November 16, 2013, about 1045 central standard time, a Piper PA-28-140 airplane, N57DB, impacted terrain after departure from the Stinson Municipal Airport (KSSF), San Antonio, Texas. The pilot, who was the sole occupant, sustained serious injuries. The airplane sustained substantial damage. The airplane was registered to and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and no flight plan was filed. The flight was originating at the time of the accident and was destined for Pleasanton Municipal Airport (KPEZ), Pleasanton, Texas. According to the pilot, he proceeded onto the runway and advanced the throttle to full forward. The engine produced "normal thrust", the airspeed reached 60 mph, and the tachometer indicated 2,700 rpm. The pilot noted that the acceleration was smooth and all indications were normal when airplane reached rotation. About 600 feet above the ground the nose of the airplane began to lower, the airspeed was still 60 mph and the tachometer indicated 2,000 rpm. He reported to air traffic control that the airplane's engine was not producing sufficient power and that he would return to the runway. The pilot pitched thenose down to prevent a stall, ensured that the throttle and mixtures controls were full forward and that the electric fuel pump was on. Seconds after the radio transmission, the airplane impacted a creek bank and a tree. At 1048, the automated weather report at KSSF reported: wind from 180 degrees at 10 knots, 10 miles visibility, ceiling broken at 3,500 feet, temperature 79 degrees Fahrenheit (F), dew point 64 degrees F and altimeter setting 29.89 inches of mercury. The pilot, age 57, held a private pilot certificate with ratings for single engine land and instrument airplane. On April 12, 2013, he was issued a third class medical certificate with no limitations. The pilot reported that he had accumulated 583 total flight hours, 231 of which we in the make and model of the accident airplane. He completed a flight review on January 17, 2012. The airplane impacted a creek bank and a tree on the departure end of runway 14 at KSSF. The airplane came to rest upright. The fuselage was broken apart and twisted right about 90 degrees from the impact with the tree. The engine remained attached to the airframe. An examination of the airframe revealed that it had been cut in multiple places for recovery and transport, but all airplane parts were accounted for. Flight control cable continuity was verified to all controls except for the cuts made during recovery process. No airframe anomalies were noted that would have precluded normal operation. A postaccident examination of the engine revealed that the spark plugs in the number 2 cylinder contained dark sooting. The cylinders were borescoped and number 2 cylinder contained sooting and was significantly darker than the other cylinders. The propeller was rotated by hand and compression and suction was observed on all cylinders. The magnetos were removed and manually rotated; each produced a spark from the respective terminals. The exhaust flame diffuser and center baffle were damaged and loose inside the muffler. The exhaust ports were not blocked. The carburetor venturi contained a stain on the inside. The oil screen was not obstructed but contained a significant amount of carbon deposits. The carburetor induction air inlet duct (air inlet hose) was single thickness scat type ducting. The material had frayed edges, loose strings and most of the wire was loose and separated from the duct. The air duct was not of the same material described for Piper Aircraft part number 99849-4, which should have been installed in accordance with Piper Aircraft Service Bulletin (SB) 356.

Aircraft

Registration
N57DB
Reported as
Piper PA 28-140
Category
Airplane
Serial number
28-25595
Built
1969
Airframe hours
3,877
Engine
Lycoming O-320-E2A, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
David H Barnhart
Registered owner
David H Barnhart
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · November 4, 2012
Departed
SSF · San Antonio, TX
Destination
PEZ · Pleasanton, TX
Airport
SSF · Stinson Muni, runway 14, 4,128 × 100 ft, asphalt

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
57
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
January 17, 2012
Seat
Left
Restraint
3-point
Flight hours
583 total · 231 in this make and model · 490 as pilot in command · 13 in the last 90 days · 11 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 10 knots
Visibility
10 statute miles
Lowest ceiling
3,500 ft broken
Temperature
79 °F, dew point 64 °F
Altimeter
29.88 inHg
Observed at
KSSF

Docket · 6

The files NTSB released with the investigation on October 14, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.9 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.