- 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.
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.