# NTSB CEN14LA058: Piper PA 28-140, N57DB, San Antonio, TX, November 16, 2013 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: November 16, 2013, 10:45 local (16:45 UTC) - Place: San Antonio, TX - Coordinates: 29.332777, -98.462501 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.3328&lon=-98.4625&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report December 15, 2014 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration, Piper, Lycoming - SAIBs cited in the narratives: [SAIB CE-14-23](https://openairdocs.org/saib/CE-14-23) (OpenAirDocs) - NTSB case key (mKey): 88439 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN14LA058 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88439/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88439 - Page: https://openairdocs.org/ntsb/CEN14LA058 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Power plant: eng air baffle sec (recip.)](https://openairdocs.org/ntsb-findings/01057112): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-28-140, 1 case](https://openairdocs.org/ntsb-findings/01057112/cases.md?model=7102802), [All aircraft, 3 cases](https://openairdocs.org/ntsb-findings/01057112/cases.md) - [Power plant: eng air baffle sec (recip.)](https://openairdocs.org/ntsb-findings/01057112): Aircraft › Aircraft power plant · Capability exceeded (probable cause); cases with it: [Piper PA-28-140, 1 case](https://openairdocs.org/ntsb-findings/01057112/cases.md?model=7102802), [All aircraft, 3 cases](https://openairdocs.org/ntsb-findings/01057112/cases.md) - [Power plant: eng air baffle sec (recip.)](https://openairdocs.org/ntsb-findings/01057112): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-28-140, 1 case](https://openairdocs.org/ntsb-findings/01057112/cases.md?model=7102802), [All aircraft, 3 cases](https://openairdocs.org/ntsb-findings/01057112/cases.md) - [Maintenance/inspections: scheduled maint checks](https://openairdocs.org/ntsb-findings/01010520): Aircraft › Aircraft handling/service · Not inspected (probable cause); cases with it: [Piper PA-28-140, 4 cases](https://openairdocs.org/ntsb-findings/01010520/cases.md?model=7102802), [All aircraft, 76 cases](https://openairdocs.org/ntsb-findings/01010520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Piper PA-28-140, 47 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7102802), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-140, 137 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102802), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N57DB-2015-06-03), registration cancelled 2015-06-03, S/N 28-25595, built 1969 (OpenAirDocs) - Reported make and model: PIPER PA 28-140 - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-25595 - Year built: 1969 - Airframe hours: 3877 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: serious; 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 ## 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 20131116025749A](https://openairdocs.org/incident/20131116025749A), Nov 16, 2013: Piper PA-28-140, San Antonio, TX, Destroyed. Aircraft lost power on takeoff from runway 14. Pilot called tower to return to the airport but crashed approximately 200 yards from end of runway onto an… ## Docket (6 files) The files NTSB released with the investigation on October 14, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88439. 5.9 MB in all. - Evidence Control Forms (item 1, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417643&FileExtension=.PDF&FileName=Evidence%20Control%20Forms-Redacted.PDF - FAA SAIB CE-14-23 (item 2, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417645&FileExtension=.PDF&FileName=FAA%20SAIB%20CE-14-23-Master.PDF - Piper Aircraft Service Bulletin 356 (item 3, .PDF, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417646&FileExtension=.PDF&FileName=Piper%20Aircraft%20Service%20Bulletin%20356-Master.PDF - Photo 1 – Airplane Wreckage (item 4, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417647&FileExtension=.PDF&FileName=Photo%201%20%E2%80%93%20Airplane%20Wreckage-Master.PDF - Photo 2 – Spark Plugs (item 5, .PDF, 951 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417650&FileExtension=.PDF&FileName=Photo%202%20%E2%80%93%20Spark%20Plugs-Master.PDF - Photo 3 – Induction Air Inlet Duct (item 6, .PDF, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417654&FileExtension=.PDF&FileName=Photo%203%20%E2%80%93%20Induction%20Air%20Inlet%20Duct-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.