# NTSB CEN20LA189: Piper PA28, N7355W, Steele, MO, May 22, 2020 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: May 22, 2020, 14:15 local (19:15 UTC) - Place: Steele, MO - Coordinates: 36.083332, -89.82917 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.0833&lon=-89.8292&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: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA - Saint Louis Flight Standards District Office - NTSB case key (mKey): 101322 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20LA189 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101322/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101322 - Page: https://openairdocs.org/ntsb/CEN20LA189 ## Probable cause The loss of oil pressure for a reason that could not be determined leading to failure of the engine connecting rod. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Unknown/Not determined (probable cause); cases with it: [Piper PA-28-180, 5 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=7102808), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-28-180, 6 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=7102808), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/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-28-180, 37 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102808), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing-flare/touchdown: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-180, 40 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102808), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The pilot stated that during cruise flight, following a low oil pressure indication, the engine started sounding unusual, began shaking violently, and quit. He determined that he would not be able to glide to the nearest airport and executed a forced landing during which, the wing sustained substantial damage. A post-accident examination revealed that the No. 2 cylinder connecting rod was separated from the crankshaft and there was a large hole in the engine crankcase. Examination of the failed connecting rod components revealed that the connecting rod strap failed due to fatigue fractures in both arms of the strap. Fretting damage on the mating surface between the connecting rod and cap indicated movement at the joint. Additionally, there were circumferential marks on the connecting rod strap and galled bearing material indicating that the bearing had spun within the connecting rod. Based on the available information the failure of the connecting rod was likely precipitated by the loss of oil pressure, ultimately resulting in the failure of the connecting rod. The reason for the loss of oil pressure could not be determined. ## Factual narrative On May 22, 2020, about 1415 central daylight time, a Piper PA-28-180, N7355W, was substantially damaged when it was involved in an accident near Steele, Missouri. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot said that while in cruise flight at 3,000 ft mean sea level (msl), he noticed that the oil pressure gauge read zero. Believing that the gauge was faulty, he started a turn to return to the departure airport to have it checked. During the turn, he noticed that the oil pressure came back to normal, but a short time later it went back to zero. Subsequently the engine started sounding unusual, began shaking violently, oil blew onto the windscreen. and the engine quit. When he determined that he would not be able to glide to the nearest airport, he executed a forced landing to a cotton field. The airplane sustained substantial damage to the left wing during the forced landing. Figure 1. Photograph of the airplane at the accident site. During a post-accident examination, oil was present on the exterior of the airplane but no evidence of a preimpact oil leak was discovered. The examination revealed that the No. 2 cylinder connecting rod was separated from the crankshaft and there was a large hole in the engine crankcase. Examination of the failed connecting rod components revealed that the connecting rod strap failed due to fatigue fractures in both arms of the strap. Fretting damage on the mating surface between the connecting rod cap and strap indicated movement at the joint. Additionally, there were circumferential marks on the connecting rod strap and galled bearing material indicating that the bearing had spun within the connecting rod. Figure 2. Photograph of the airplane’s engine showing the broken connecting rod and damage to the engine case. Review of the engine maintenance records indicated that the most recent engine overhaul was completed on September 11, 1998. The most recent annual inspection was completed on May 5, 2020, and the engine had accumulated 1063.77 hours since overhaul as of that date. Lycoming Service Instruction 1009BE, dated April 24, 2020, listed an operating hour time between overhaul of 2,000 hours for the O-360-A3A, however, the service instruction further stated: “All engine models are to be overhauled within twelve (12) calendar years of the date they first entered service or of last overhaul. This calendar year time period TBO is to mitigate engine deterioration that occurs with age, including corrosion of metallic components and degradation of non-metallic components such as gaskets, seals, flexible hoses and fuel pump diaphragms.” ## Aircraft - Registration: [N7355W](https://openairdocs.org/deregistered/N7355W-2021-04-30), registration cancelled 2021-04-30, S/N 28-1235, built 1963 (OpenAirDocs) - Reported make and model: PIPER PA28 (180) - Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-1235 - Year built: 1963 - Engines: Lycoming O-360-A3A reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 5, 2020 - Departed: HKA, Blytheville, AR - Destination: POF, Poplar Bluff, MO ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: minor; private; airplane ratings: single-engine land; medical: class 1, without waivers/limitations; last flight review January 21, 2019; seat: left; restraint: lap only; flight hours: 150 total, 116 in this make and model, 111 as pilot in command, 18 in the last 90 days, 10 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 280° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: 4,000 ft broken ## 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 20200522007119A](https://openairdocs.org/incident/20200522007119A), May 22, 2020: Piper PA-28-180, Steele, MO, Substantial damage. Received notification of an aircraft accident involving a Piper PA-28-180 cherokee with a registration of N7355W. Aircraft was at 3,000 feet, level flight… ## Other investigations on N7355W (1) 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. - [NTSB GAA16CA302](https://openairdocs.org/ntsb/GAA16CA302), Jun 9, 2016: Piper PA 28 (N7355W), Rowesville, SC, substantial damage. Probable cause: The fuel line failure between the fuel transducer and the carburetor, which resulted in a total loss of engine power and subsequent forced off airport landing. ## Docket (6 files) The files NTSB released with the investigation on February 24, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101322. 48.1 MB in all. - Materials laboratory factual report 21-014 (item 1, PDF, 7 pages, 10 photos, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12162469&FileExtension=pdf&FileName=21-014-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 2, PDF, 9 pages, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12294301&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Pilot statement (item 3, PDF, 1 page, 35.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12332466&FileExtension=pdf&FileName=Pilot%20Statement_Redacted-Rel.pdf - Record of conversation with FAA inspector (item 4, PDF, 1 page, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12354934&FileExtension=pdf&FileName=ROC%20with%20FSDO%20Inspector-Rel.pdf - Photographs (item 5, PDF, 2 pages, 503 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12354271&FileExtension=pdf&FileName=Photos-Rel.pdf - Excerpts from airframe logbook (item 6, PDF, 9 pages, 6.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12354986&FileExtension=pdf&FileName=airframe%20log_Redacted-Rel.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.