# NTSB CEN15LA228: Piper PA 28-161, N3024S, Ranger, TX, May 12, 2015 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: May 11, 2015, 22:41 local (May 12, 2015, 03:41 UTC) - Place: Ranger, TX - Coordinates: 32.429443, -98.623886 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.4294&lon=-98.6239&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 1 serious, 1 uninjured - Status: Completed, report January 18, 2017 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Flight Standards District Office, Piper Aircraft, Lycoming Engines - NTSB case key (mKey): 91155 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN15LA228 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91155/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91155 - Page: https://openairdocs.org/ntsb/CEN15LA228 ## Probable cause A total loss of engine power during cruise flight due to piston fatigue cracking for reasons that could not be determined due to postfracture smearing damage. ## 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-28-161, 3 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=7102803), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Contributed to outcome (probable cause); cases with it: [Piper PA-28-161, 9 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=7102803), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md) - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Fatigue/wear/corrosion (probable cause); cases with it: [Piper PA-28-161, 3 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=7102803), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-28-161, 22 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102803), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-161, 19 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102803), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Piper PA-28-161, 9 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=7102803), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## Analysis The commercial pilot reported that, during cruise flight on a night training flight, he heard "two knocks" coming from the engine, followed by a total loss of power. After attempting to restart the engine without success, the pilot executed a forced landing onto a field, during which the airplane impacted a tree. Teardown of the engine revealed that the No. 4 piston crown and connecting rod were fractured. Laboratory examination revealed two thumbnail-shaped fatigue cracks on the piston crown's underside near an oil drain hole along the top oil groove on the piston circumference. The fatigue cracks had propagated from initiation sites along the circumferential oil groove at or near the oil drain hole. The cause of the initiation of the fatigue cracks could not be determined due to postfracture smearing damage. ## Factual narrative On May 11, 2015, about 2241 central daylight time, a Piper PA-28-161 airplane, N3024S, was substantially damaged during a forced landing near Ranger, Texas. The pilot was seriously injured and the passenger was not injured. The airplane was registered to a private individual and operated by Delta Qualiflight Academy under the provisions of 14 Code of Federal Regulations Part 91 as a training flight. Night visual meteorological conditions prevailed for the flight, with no flight plan filed. The flight departed from Abilene Regional Airport (ABI), Abilene, Texas about 2210 and was destined for Cleburn Regional Airport (CBN), Cleburn, Texas. While in cruise at 5,500 above mean sea level, the pilot reported that he heard "two knocks" from the engine, followed by propeller stoppage and a total loss of power. After attempting without success to regain engine power, the pilot executed a forced landing onto a field, during which the left wing was damaged due to impact with a tree. On-site inspection of the engine revealed two holes on the top of the engine case. The airplane was recovered to the facilities of Air Salvage of Dallas and the engine was subsequently removed for examination. The crank shaft would only rotate 270 degrees before a hard lock was observed. The cylinders were removed except for the number 3 cylinder, which had damage to its skirt area. Teardown revealed the number 4 piston crown and connecting rod were fractured, with metallic debris throughout the engine case and oil filter. Although the number 4 connecting rod displayed substantial impact damage, there was no discoloration or signs of high heat. The number 4 piston crown, pieces of the connecting rod, piston wrist pin, and piston pin plug remnants were shipped to the National Transportation Safety Board Materials Laboratory for further examination. Laboratory examination revealed two thumbnail-shaped fatigue cracks on the piston crown underside, each located near an oil drain hole along the top oil groove on the piston circumference. Closer examination of the crack features found that they had propagated from initiation sites along the circumferential oil groove, at or near the oil drain hole. Post-fracture smearing damage prevented determination of the cause of the initiation of the fatigue cracks. The engine was a Lycoming O-320-D3G, with serial number L-10238-39A. The airframe had a total time of 10,672 hours at the last inspection on May 4, 2015. The engine had a total time of 9,309 hours and 2,135 hours since the last overhaul, which included replacement of the pistons and rings. During the last engine inspection, which occurred about 11 hours prior to the accident, the engine oil and filter were changed. An oil analysis was not performed during this or previous inspections since the last overhaul. Lycoming Engines Service Instruction 1009AW, dated February 24, 2014, which was current at the time of the accident, stated "if an engine is being used in 'frequent' typeservice and accumulates 40 hours or more per month, and has been so operated consistently since being placed in service, add 200 hours to time between overhaul (TBO) time". The engine usage pattern did not meet the requirement for a 200-hour extension past the normally recommended 2,000 hour TBO. The director of maintenance at Delta Qualiflight Academy stated that his organization typically overhauled engines at about 3,000 hours. Engine overhaul times are not mandated in 14 Code of Federal Regulations Part 91. ## Aircraft - Registration: [N3024S](https://openairdocs.org/deregistered/N3024S-2016-08-22), registration cancelled 2016-08-22, S/N 28-7916297, built 1979 (OpenAirDocs) - Reported make and model: PIPER PA 28-161 - Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7916297 - Year built: 1979 - Airframe hours: 10672 - Engines: LYCOMING O-320-D3G 160 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, May 4, 2015, 11 hours before - Departed: KABI, Abilene, TX - Destination: KCBN, Cleburn, TX - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 29; injuries: serious; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review March 16, 2015; seat: left; flight hours: 415 total, 390 in this make and model, 280 as pilot in command, 60 in the last 90 days, 20 in the last 30 days ## Weather - Conditions: Visual (VMC), Night - Wind: 10° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 52 °F - Altimeter: 30.20 inHg - Observed at: KSEP, 20 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 20150511007609A](https://openairdocs.org/incident/20150511007609A), May 11, 2015: Piper PA-28-161, Ranger, TX, Substantial damage. During cruise flight at night the pilot reported that the engine made 2 loud bangs and the propeller stopped. An engine restart was unsuccessful and the pilot… ## Docket (5 files) The files NTSB released with the investigation on November 7, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91155. 9.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446183&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Photos of Engine (item 2, .PDF, 3 photos, 373 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446184&FileExtension=.PDF&FileName=Photos%20of%20Engine-Master.PDF - Materials Laboratory Factual Report (item 3, .PDF, 20 photos, 7.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446185&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report-Master.PDF - Lycoming Service Instruction 1009AW - Current at Time of Accident (item 4, .PDF, 636 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446186&FileExtension=.PDF&FileName=Lycoming%20Service%20Instruction%201009AW%20-%20Current%20at%20Time%20of%20Accident-Master.PDF - Wreckage Release (item 5, .PDF, 229 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446187&FileExtension=.PDF&FileName=Wreckage%20Release-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.