# NTSB CEN22LA227: Piper PA-28RT-201T, N2148J, Morgan, TX, May 29, 2022 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: May 29, 2022, 15:27 local (20:27 UTC) - Place: Morgan, TX - Coordinates: 31.99, -97.55 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=31.9900&lon=-97.5500&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA, Flight Standards District Office - NTSB case key (mKey): 105189 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22LA227 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105189/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105189 - Page: https://openairdocs.org/ntsb/CEN22LA227 ## Probable cause A partial loss of engine power due to a corrosion-related fatigue crack of the No. 3 cylinder barrel. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Inadequate inspection (probable cause); cases with it: [Piper PA-28RT-201T, 2 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=7102817), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-28RT-201T, 1 case](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=7102817), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) - [Terrain: rough terrain](https://openairdocs.org/ntsb-findings/03021015): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28RT-201T, 1 case](https://openairdocs.org/ntsb-findings/03021015/cases.md?model=7102817), [All aircraft, 442 cases](https://openairdocs.org/ntsb-findings/03021015/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-28RT-201T, 1 case](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=7102817), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot; cases with it: [Piper PA-28RT-201T, 5 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102817), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Piper PA-28RT-201T, 3 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=7102817), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) ## 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](https://openairdocs.org/deregistered/N2148J-2024-02-03), registration cancelled 2024-02-03, S/N 28R-7931012, built 1978 (OpenAirDocs) - Reported make and model: PIPER PA-28RT-201T - Registry model: [Piper PA-28RT-201T](https://openairdocs.org/model/piper-pa-28rt-201t) (registry code 7102817) (OpenAirDocs) - Registry engine: [Continental TSIO-360 series](https://openairdocs.org/engine/continental-tsio-360-series) (registry code 17019, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7931012 - Year built: 1978 - Airframe hours: 3804 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: none; 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 ## 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 20220529022899A](https://openairdocs.org/incident/20220529022899A), May 29, 2022: Piper PA-28RT-201T, Morgan, TX, Substantial damage. [privacy data omitted], A Piper PA-28RT, was substantially damaged when it experienced a loss of power and the PIC noticed a burning smell inside the cockpit.… ## Other investigations on N2148J (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 CEN14LA474](https://openairdocs.org/ntsb/CEN14LA474), Jul 27, 2014: Piper PA 28RT-201T (N2148J), Houston, TX, substantial damage. Probable cause: The landing gear’s failure to extend for reasons that could not be determined based on the available evidence. ## Docket (6 files) The files NTSB released with the investigation on January 30, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105189. 13.8 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 10 pages, 6.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15566316&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Photos of airplane at accident site (item 2, PDF, 2 pages, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15565714&FileExtension=pdf&FileName=Photos-Rel.pdf - Materials laboratory factual report 23-018 (item 3, PDF, 9 pages, 6 photos, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15264433&FileExtension=pdf&FileName=Materials%20Laboratory%20Factual%20Report%2023-018-Rel.pdf - Excerpt of maintenance logs (item 4, PDF, 3 pages, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16158865&FileExtension=pdf&FileName=Engine%20Logs%20-%20excerpt%20--_Redacted-Rel.pdf - Correspondence with mechanic (item 5, PDF, 1 page, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16509216&FileExtension=pdf&FileName=Correspondence%20with%20Mechanic-Rel.pdf - Manufacturer cylinder inspection guidance (item 6, PDF, 17 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16509389&FileExtension=pdf&FileName=M-0%20Title%20Page%20and%20Cylinder%20Inspection%20Excerpt-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.