CHI93LA311

NTSB accident investigation · Piper PA-28R-200 · Millard, NE · August 6, 1993

Accident · No injuriesLimited investigationFinal report
Date
August 6, 1993, 15:15 local (20:15 UTC)
Place
Millard, NE
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N233LCPiper PA-28R-200
Weather
Visual (VMC) · Day
Status
Completed · report December 2, 1994
Report
Approved by Office Director
FAA report
19930806028079A
Case key
9273

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

Improper maintenance/inspection of the aircraft by (other) maintenance personnel, and subsequent blockage of the induction air system by an object (alternate air door) that was not removed during previous maintenance.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(partial) - mech failure/malfTakeoff - initial climb
Maintenance,inspection - improperOther maintenance personnelCause
Induction air control,alternate air/door - not removed
Induction air ducting - blocked(partial)Cause
Forced landingDescent - emergency
In flight collision with objectLanding
Object - pole
In flight collision with terrain/waterLanding

Analysis

The pilot reported that after takeoff, a gradual loss of power occurred during the initial climb-out. During a forced landing about 3/4 mile northwest of the airport, the airplane collided with a soccer field goal post, then crashed to the ground. During a post-accident test run, the engine operated to the manufacturer's specifications. No anomalies were found in the exhaust or fuel distribution systems. Further exam revealed that an object (alternate air door, pn: 23809-07) had lodged inside the engine induction system, adjacent to the alternate air adapter assembly. It was for an earlier model PA-28R aircraft & should not have been installed on this aircraft. The air box cover on this aircraft had been replaced in 1986 with a pn:67745-00 door, which was the correct part number. There was evidence that the incorrect door had been previously installed, but it had broken off & was ingested downstream in the induction system. Evidently, the mechanic, who replace the air box cover, had overlooked or could not see the broken door.

Factual narrative

On August 6, 1993, at 1515 central daylight time (CDT), a Piper PA-28R-200, N233LC, registered to the Skyhawk Flying Club, Incorporated, of Omaha, Nebraska, and piloted by a private pilot, was substantially damaged during a forced landing shortly after takeoff. Visual meteorological conditions prevailed at the time of the accident. The personal 14 CFR Part 91 flight was not operating on a flight plan. The pilot and three passengers reported no injuries. The flight originated from Millard, Nebraska, at 1515 CDT.

The pilot stated the airplane's engine sound diminished along with its climb performance shortly after takeoff. The airplane began a descent shortly after it began the initial climb and struck a soccer field goal post prior to colliding with the ground. One witness stated she did not hear N233LC's engine as it was descending. This witness observed the airplane collide with the soccer field goal post and ground. A second witness observed N233LC "...flying very low..." and collide with the goal post and ground.

The on-scene investigation was conducted by a Federal Aviation Administration Principal Maintenance Inspector (PMI). N233LC's engine was removed from the airframe and test run. The test run revealed the engine was capable of operating to the manufacturer's specifications. The PMI examined the fuel distribution and exhaust systems for damage which could result in an engine power loss. He stated he did not find anomalies within the systems. The PMI observed an unattached alternate air door (door) inside the air induction system. The door was found lodged in the alternate air adapter assembly.

According to the PMI, "The Piper PA-28R-180 and early model PA- 28R-200 Arrows incorporated an alternate air door on the cover of the induction air box assembly. The door, P/N 23809-07, which was in the induction system of this aircraft was for the earlier model PA-28R-200 Arrows and should not have been installed on this aircraft. The air box cover on this aircraft was replaced in 1986 with a P/N 67745-00 which is the correct part number for this aircraft." The PMI stated the previously installed incorrect door had broken off and was ingested downstream in the induction system. The PMI's examination statement is appended to this report.

Maintenance records for N233LC reveal the installation of a "...new induction air filter box cover," on November 10, 1986. The airplane had been inspected over a period of seven years without the incorrect door being found in the induction system. Pertinent excerpts of the maintenance records are appended to this report.

N233LC's propeller hub, governor, and blades were examined. The result of the examination found the propeller hub and governor functioned to manufacturer's specifications. The propeller tear down reports are appended to this report.

Aircraft

Registration
N233LC
Reported as
Piper PA-28R-200
Category
Airplane
Serial number
28R7535309
Engine
Lycoming IO-360-C1C, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Skyhawk Flying Club, Inc
Airworthiness certificate
Standard, Normal
Departed
MLE
Destination
MKT · Mankato, NE
Flight plan
VFR
Airport
MLE · Millard, runway 30, 3,800 × 75 ft, concrete

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
47
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
680 total · 11 in this make and model · 593 as pilot in command · 19 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
30° at 4 knots
Visibility
15 statute miles
Lowest ceiling
25,000 ft broken
Temperature
73 °F, dew point 52 °F
Altimeter
30.00 inHg
Observed at
OFF, 10 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.