CHI97LA097

NTSB accident investigation · Piper PA-28-235 · Des Moines, IA · April 2, 1997

Accident · No injuriesLimited investigationFinal report
Date
April 1, 1997, 18:24 local (Apr 2, 1997, 00:24 UTC)
Place
Des Moines, IA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N9004WPiper PA-28-235
Weather
Visual (VMC) · Day
Status
Completed · report September 5, 1997
Report
Approved by Office Director
FAA report
19970402004089A
Case key
10537

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

oil contamination and starvation due to the inadequate maintenance inspection of the pilot/owner. Factors included the deterioration of the piston pin plug, the connecting rod failure, and the unsuitable terrain for landing.

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(total) - mech failure/malfCruise
Engine assembly,connecting rod - failureFactor
Engine assembly,bearing - meltedFactor
Engine assembly,other - deterioratedFactor
Lubricating system - contaminationCause
Lubricating system - starvationCause
Maintenance,inspection - inadequatePilot in commandCause
Forced landingEmergency descent/landing
Complete gear collapsedLanding - roll
Terrain condition - rough/uneven
Unsuitable terrain or takeoff/landing/taxi area - selectedPilot in commandFactor

Analysis

The pilot reported that about 40 minutes after takeoff the tachometer started surging. The oil pressure gauge dropped to zero and the engine started knocking. The engine seized and the pilot landed the airplane in a soy bean field. During landing rollout the airplane hit some large ruts which collapsed the landing gear. The engine examination indicated the number six connecting rod had failed and knocked a hole in the top of the crankcase. The number three upper piston pin plug had deteriorated and was contaminating the engine with aluminum metal. The oil filter was opened and evidence of aluminum metal contamination was found. The cam shaft and tappets indicated various stages of spalling. Rust was noted inside all cylinder walls and all the connecting rods had surface rust on them. In addition to the separated number six connecting rod, the number four and five connecting rods were blued and not free to move. The pilot reported that the oil filter was not opened during the oil changes to inspect for metal contamination. The pilot was unaware that the engine oil filter indicated that the oil system was contaminated with metal particles.

Factual narrative

On April 1, 1997, at 1824 central standard time, a Piper PA-28-235, N9004W, sustained substantial damage during a forced landing due to loss of engine power near Des Moines, Iowa. The commercial pilot was not injured. The 14 CFR Part 91 flight departed Morning Star Airport, Des Moines, Iowa, on a local flight. Visual meteorological conditions prevailed and no flight plan had been filed.

The pilot reported that he had preflighted the airplane thoroughly before departure. After takeoff he climbed to about 2,500 feet mean sea level (msl) and was at cruise power with the propeller set at 2,300 rpm. About 40 minutes after takeoff, the tachometer went from 2,300 rpm to 2,600 rpm, and then down to 2,200 rpm. The pilot reported that the engine sounded "okay," with no backfiring, mis-firing, or rough running of any kind. He pulled the carburetor heat, checked magnetos, fuel switches, and set the mixture to rich. He reported that he saw the oil pressure gauge read zero about 30 seconds before he made the decision to land in a field for a forced landing. The engine was knocking and it seized before the pilot landed the airplane in a soy bean field. During landing rollout the airplane hit some large ruts which collapsed the landing gear.

The engine and engine logbooks were examined. It was determined that the engine was a remanufactured engine that had been installed on the airplane in 1980. The engine had about 600 hours total operating time since being installed on the airplane. The pilot reported that one of the reasons he had purchased the airplane was because the engine was a low time engine.

The engine examination revealed that the number six connecting rod had separated and knocked a hole in the top of the crankcase. During the engine teardown, it was determined that the number three upper piston pin plug had been deteriorating and contaminating the engine with aluminum metal. The oil filter was opened and evidence of aluminum metal contamination was found. The oil pressure screen was inspected for contamination and it had some metal particles in the screen. The cam shaft and tappets indicated various stages of spalling, some advanced. Rust was noted inside all cylinder walls and all the connecting rods had surface rust on them. The number six connecting rod was black in color, and the number four and five connecting rods were blued and not free to move. The number five connecting rod bearing was burnished and heat distressed.

The pilot reported that the airplane was flown about 75 hours a year. Oil was changed on the airplane about three times a year. The oil filter was not opened during the oil changes to inspect for metal contamination. The pilot reported that he was unaware that the engine oil filter indicated that the oil system was contaminated with metal particles.

Aircraft

Registration
N9004W
Reported as
Piper PA-28-235
Category
Airplane
Serial number
28-10585
Airframe hours
2,321
Engine
Lycoming O-540 B4B5, 235 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
William B. Sevenbergen
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 24, 1996 · 70 hours before
Departed
Y76

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
48
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
1,568 total · 848 in this make and model · 1,508 as pilot in command · 12 in the last 90 days · 5 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 11 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
59 °F, dew point 36 °F
Altimeter
30.00 inHg
Observed at
DSM, 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.