# NTSB CHI91LA121: Piper PA-28-161, N2366W, Schaumburg, IL, April 5, 1991

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Limited investigation · Final report
- Date: April 5, 1991, 11:00 local (17:00 UTC)
- Place: Schaumburg, IL
- Coordinates: 41.979682, -88.080574 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=41.9797&lon=-88.0806&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: Minor injuries
- Injuries: 1 minor, 3 uninjured
- Status: Completed, report March 31, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 15033
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI91LA121
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15033/pdf
- Page: https://openairdocs.org/ntsb/CHI91LA121

## Probable cause

THE MECHANIC'S NOT UNDERSTANDING THE IDENTIFYING MARKS ON THE REPLACEMENT PART.  A FACTOR IN THE ACCIDENT WAS THAT THE MECHANIC WAS PROVIDED WITH AN IMPROPER PART.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power(total) - mech failure/malf, takeoff - initial climb
  - engine assembly,cylinder - improper
  - maintenance,replacement - misjudged, company maintenance personnel (cause)
  - material inadequate,improper, company/operator management (contributing factor)
  - engine assembly,piston - seized
  - remedial action - not possible
- Forced landing, descent - emergency
- On ground/water collision with object, landing
  - object - tree(s)

## Analysis

THE AIRPLANE'S ENGINE SEIZED AT 70 FEET ON TAKEOFF CLIMB, AND THE PILOT EXECUTED A FORCED LANDING.  THE ENGINE HAD RECENTLY UNDERGONE REPLACEMENT OF THE NUMBER 1 CYLINDER; NO OTHER PARTS WERE CHANGED.  PAINT MARKS ON THE REPLACEMENT CYLINDER INDICATED IT HAD BEEN CHROME PLATED TO STANDARD BORE. THE 3 REMAINING CYLINDERS AND ALL PISTONS WERE MARKED 0.010 OVERSIZE.  THE OPERATOR'S DIRECTOR OF MAINTENANCE OBTAINED THE REPLACEMENT PART AND PROVIDED IT TO THE MECHANIC. THE OPERATOR'S MECHANIC STATED HE WAS UNAWARE WHAT THE CYLINDERS' COLOR MARKS SIGNIFIED AND HAD NOT MEASURED MATCHING PARTS DURING REPLACEMENT.

## Aircraft

- Registration: [N2366W](https://openairdocs.org/aircraft/N2366W), registered now, S/N 28-8516046 (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: 28-8516 046
- Airframe hours: 3528
- Engines: LYCOMING O-320-D3G 160 horsepower reciprocating
- Damage: Substantial damage
- Flight: Instructional, Part 91
- Operator: Northwest Flyers Inc
- Registered owner: Three B'S Aero
- Airworthiness certificate: Standard, Normal
- Last inspection: 100 hour, March 22, 1991, 25 hours before
- Airport: 06C, Schuamburg Air Park

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 24; airline transport, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: right; flight hours: 2,325 total, 1,550 in this make and model, 2,225 as pilot in command, 250 in the last 90 days, 90 in the last 30 days, 2 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 210° at 11 knots
- Visibility: 7 statute miles
- Lowest ceiling: none
- Temperature: 70 °F, dew point 54 °F
- Altimeter: 30.00 inHg
- Observed at: ORD, 9 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 19910405009229A](https://openairdocs.org/incident/19910405009229A), Apr 5, 1991: Piper PA28161, Chicago/Schaumb, IL, Substantial damage. Engine failed on climbout. Crash landed in marsh. NR1 cylinder just replaced failed. Mechanic failed measure size.

## Other investigations on N2366W (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 CHI99LA279](https://openairdocs.org/ntsb/CHI99LA279), Aug 8, 1999: Piper PA-28-161 (N2366W), Schaumburg, IL, substantial damage. Probable cause: the CFI's delay in taking remedial action to maintain directional control of the airplane. A factor associated with the accident was the student's improper use of the brakes.

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.

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