# NTSB DEN00IA093: Piper PA-32R-300, N424TP, Erie, CO, May 22, 2000 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: May 22, 2000, 17:00 local (23:00 UTC) - Place: Erie, CO - Coordinates: 40.019958, -105.040924 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.0200&lon=-105.0409&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report December 4, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 49271 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN00IA093 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/49271/pdf - Page: https://openairdocs.org/ntsb/DEN00IA093 ## Probable cause Improper installation of cylinders by unknown maintenance personnel who failed to torque the cylinder stud nuts sufficiently. ## 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, climb - to cruise - engine assembly,cylinder - separation - engine assembly,cylinder - loose part/bolt/nut/clamp/etc (cause) - maintenance,installation - improper, other maintenance personnel (cause) - Forced landing, descent - emergency - terrain condition - open field ## Analysis During climb to cruise, on an IFR flight plan, in visual conditions, the engine lost all power approximately 10 minutes after takeoff. A forced landing was made in an open field and no damage was incurred during the landing. Examination of the engine provided evidence the number 2 cylinder had separated from the case and had lodged in the cowl. Detailed examination provided evidence that the cylinder hold down studs had failed and were 'necked-down' at the fracture points. The rod bolts then failed and the piston reversed itself and lodged in the case. No signatures of oil starvation or heat distress were found. Examination at an engine overhaul facility provided evidence that none of the hold down stud nuts on the remaining five cylinders had sufficient torque. ## Factual narrative On May 22, 2000, at 1700 mountain daylight time, a Piper PA-32R-300, N424TP, sustained minor damage when the engine failed catastrophically during climb to cruise. The two private pilots were not injured. The flight was operating on an instrument flight rules flight plan, in visual conditions, under the provisions of Title 14 CFR Part 91. The landing site was about 10 miles north of Erie Tri-County Airport, Lafayette, Colorado, and the takeoff occurred from Jefferson County Airport, Broomfield, Colorado, about 20 miles south of the landing site. As the flight was climbing through about 8,000 feet above mean sea level (msl), [3,000 feet above ground level] the engine lost all power and oil was observed by the pilot on the cowl and wind screen. The pilot made an emergency landing in a field. No damage was incurred as a result of the landing. Initial examination of the engine revealed that the number 2 cylinder separated from the case and all the cylinder hold-down studs had sheared. The connecting rod contacted the skirt of the piston and fractured the skirt and jammed. The piston and connecting rod rotated nearly 180 degrees and the piston lodged in the case. The case revealed some piston impact damage. One connecting rod bolt and both connecting rod nuts with the bolt ends were recovered along with the connecting rod cap and both halves of the main rod bearings. One inner cylinder base nut with the stud end attached was also recovered. All fragments were found inside the engine cowling. Visual examination of the portions of the connecting rod bolts and the cylinder hold down studs provided evidence of "necking" at the fracture points. The bearing surfaces of the connecting rod, the rod and cap had no signatures of oil starvation or heat distress. The sequence of events, as provided by the witness marks, provided evidence that the connecting rod bolt failure was secondary in nature and resulted from cylinder separation. The cylinder was visually inspected and no paint or foreign material on the crankcase mounting surface or cylinder base surface was found. The other five cylinders had torque putty on all the cylinder hold down nuts. Examination of the engine at an engine overhaul facility provided evidence that none of the hold down nuts on the remaining five cylinders had sufficient torque. ## Aircraft - Registration: [N424TP](https://openairdocs.org/aircraft/N424TP), registered now, S/N 32R-7780332, built 1977 (OpenAirDocs) - Reported make and model: Piper PA-32R-300 - Registry model: [Piper PA-32R-300](https://openairdocs.org/model/piper-pa-32r-300) (registry code 7103213) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 32R-7780332 - Airframe hours: 4976 - Engines: Lycoming TO-540-KIG5D 300 horsepower reciprocating - Damage: Minor damage - Flight: Personal, Part 91 - Operator: Brian J. Inskeep - Registered owner: Derriaircraft - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, April 18, 2000, 70 hours before - Departed: BJC, BROOMFIELD, CO - Destination: STJ, SAINT JOSEPH, MO - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 31; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 376 total, 80 in this make and model, 345 as pilot in command, 48 in the last 90 days, 25 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 290° at 12 knots - Visibility: 60 statute miles - Lowest ceiling: 16,000 ft broken - Temperature: 84 °F, dew point 37 °F - Altimeter: 29.00 inHg - Observed at: BJC, 20 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). - [Incident 20000522032449I](https://openairdocs.org/incident/20000522032449I), May 22, 2000: Piper PA32R300, Erie, CO, Minor damage. (-23)Aircraft was climbing through 8000 feet above mean sea level when the front left engine cyclinder and pistion separated from engine and lodge inthe cowl.… 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.