CEN22LA227

NTSB accident investigation · Piper PA-28RT-201T · Morgan, TX · May 29, 2022

Accident · No injuriesClass 3 · LimitedFinal report
Date
May 29, 2022, 15:27 local (20:27 UTC)
Place
Morgan, TX
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N2148JPiper PA-28RT-201T
Defining event
Enroute: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA, Flight Standards District Office
FAA report
20220529022899A
Case key
105189

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 due to a corrosion-related fatigue crack of the No. 3 cylinder barrel.

Findings · 5

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.

Engine (reciprocating): recip engine power sectionAircraft › Aircraft power plant · Inadequate inspectionPiper PA-28RT-201T: 2 casesAll aircraft: 233 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · FailurePiper PA-28RT-201T: 1 caseAll aircraft: 497 casesProbable cause
Terrain: rough terrainEnvironmental issues › Physical environment · Contributed to outcomePiper PA-28RT-201T: 1 caseAll aircraft: 442 cases
Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · Fatigue/wear/corrosionPiper PA-28RT-201T: 1 caseAll aircraft: 373 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

While in cruise flight, the pilot observed the manifold pressure drop, followed by a loud rattling engine noise with strong vibrations. The pilot shut down the engine and diverted toward a nearby airport. The pilot reported that he thought the airplane was too high on the downwind leg; however, after he turned the airplane onto the final leg, he realized that the headwind would prevent him from making it to the runway. The pilot performed a forced landing into rough terrain short of the runway, which resulted in substantial damage to the right wing. Postaccident examination of the No. 3 cylinder revealed the cylinder barrel was fractured between the cooling fins and the threaded section used for mounting the cylinder head. A metallurgical examination revealed a fatigue crack that originated at a corrosion pit on the outer diameter surface of the cylinder barrel. The inboard-facing side of the first cylinder cooling fin was tinted black for a 180° arc, with the center of the arc in line with the fatigue crack. Manufacturer guidance includes inspection of cylinder fins for any signs of oil or soot leakage that might indicate a cylinder or head-to-barrel junction structural integrity breach. The engine was operated about 30 hours since the last annual inspection.

Factual narrative

On May 29, 2022, about 1527 mountain daylight time, a Piper PA-28RT-201T, N2148J, was substantially damaged when it was involved in an accident near Morgan, Texas. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, while in cruise flight at 9,500 ft mean sea level (msl), he observed the throttle lever creep back and a drop in manifold pressure. The pilot descended to about 5,500 ft msl and then observed a loud rattling engine noise with strong vibrations. The pilot shut down the engine, located a nearby airport, and executed a forced landing to runway 17 at W4 Ranch Airport, Morgan, Texas. The pilot reported that he thought the airplane was too high on the downwind leg; however, after turning onto the final leg, he realized that the headwind was going to prevent him from making it to the runway. During landing, the airplane touched down short of the runway in an area of rough terrain, which resulted in substantial damage to the right wing. Examination of the No. 3 cylinder at the National Transportation Safety Board Materials Laboratory revealed the cylinder barrel had fractured in the smooth-walled region located between the cooling fins and the threaded section used for mounting the cylinder head. The fracture surface was examined with the aid of a stereomicroscope. Features were consistent with a fatigue crack that originated along the outer diameter surface of the barrel at a corrosion pit. The fracture surface near the pit exhibited radial lines and flat feathery features that were consistent with crack initiation and progression due to cyclic fatigue. The inboard-facing side of the first cylinder cooling fin and adjoining material was tinted black for about a 180° arc. The fatigue crack was in line with the center of the black tinted arc. The Continental Engine Standard Maintenance Practice Manual, Section 6-4.11.1, includes the following information for a cylinder visual inspection: Inspect the external surfaces of the cylinder head including the fins, intake and exhaust ports, top and bottom spark plug bosses and fuel nozzle bosses for cracks, exhaust flange leakage or any signs of oil, fuel, or soot leakage indicating cylinder or the head-to-barrel junction structural integrity breach. A review of maintenance records revealed the compression checks of the No. 3 cylinder were lower than the other cylinders during the last 3 annual inspections. The engine was operated about 30 hours since the last annual inspection which was performed on July 19, 2021. The mechanic did not respond to requests for an interview regarding the recent maintenance of the engine.

Aircraft

Registration
N2148J
Reported as
Piper PA-28RT-201T
Category
Airplane
Serial number
28R-7931012
Built
1978
Airframe hours
3,804
Engine
Continental TSIO 360FB, 200 hp, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 19, 2021 · 30 hours before
Departed
PPA · Pampa, TX
Destination
AXH · Houston, TX
Airport
84TE · W4 Ranch Airport, runway 17, 4,500 × 50 ft, asphalt
Equipment
ADS-B, Auto-pilot, Electronic flight bag or handheld device

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
58
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
February 8, 2022
Seat
Left
Restraint
3-point
Flight hours
331 total · 252 in this make and model · 15 in the last 90 days · 8 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 18 knots, gusting 24
Visibility
10 statute miles
Lowest ceiling
None
Temperature
93 °F, dew point 68 °F
Altimeter
29.67 inHg
Observed at
KINJ, 23 nm away
METAR
KINJ 292035Z AUTO 16018G24KT 10SM CLR 34/20 A2967 RMK AO2 T03400200

Docket · 6

The files NTSB released with the investigation on January 30, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 13.8 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.

Other investigations on N2148J · 1

Matched to the same aircraft by N-number and date.