DEN06LA044

NTSB accident investigation · Piper PA-28RT-201T · Parker, CO · February 25, 2006

Accident · No injuriesLimited investigationFinal report
Date
February 25, 2006, 08:45 local (15:45 UTC)
Place
Parker, CO
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N2939VPiper PA-28RT-201T
Weather
Visual (VMC) · Day
Status
Completed · report August 29, 2006
Report
Approved by Office Director
Parties
Teledyne Continental Motors, Inc., FAA Flight Standards District Office
FAA report
20060225003539A
Case key
63279

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

The NTSB’s determination of the probable cause, and any contributing factors.

the improper maintenance procedures resulting in the unseating of the number two main bearing. Contributing factors include the mechanic's improper troubleshooting procedures, and the pilot's improper decision to continue operating the airplane with known internal excessive engine wear, and engine rpm issues.

Analysis

The pilot stated that during cruise flight the engine rpm increased to an "over speed condition." When he increased power, he could not keep the rpm under redline and he elected to perform a forced landing. During the landing, the landing gear collapsed resulting in substantial damage. The pilot stated they had been having difficulty obtaining full rpm from the engine. He stated that the propeller governor had been adjusted several times, but full rpm was never obtained. On November 16, 2005, at an engine tachometer time of 1,959.37, the oil and filter were removed and replaced, and an oil sample was sent for analysis. The results from that analysis indicated "excessive wear." Removal of the oil suction screen revealed metal contamination inside and outside the screen. Examination of the propeller governor revealed the adjustment screw had been adjusted beyond its maximum stop. The propeller governor was removed and the screen between the governor and the engine was entirely obstructed with metal contamination. Removal and examination of the oil filter revealed metal contamination. Broken portions of the number two main bearing were found within the oil sump. Breakaway torque values revealed that the number two and number three cylinder throughbolt nuts, at the cylinder flange, were loose at 500 inch/pounds. Further examination revealed metal contamination throughout the engine, including the oil pump and the oil cooler. No other anomalies were noted with the airframe, propeller, or engine.

Factual narrative

The factual narrative569 words

On February 25, 2006, approximately 0845 mountain standard time, a Piper PA-28RT-201T, N2939V, piloted by commercial pilot, was substantially damaged during a forced landing 17 nautical miles south of Front Range Airport (FTG), near Parker, Colorado. Visual meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 CFR Part 91 without a flight plan. The pilot and private pilot rated passenger on board reported no injuries. The cross-country flight departed FTG approximately 0830, and was en route to Buena Vista, Colorado.

According to the pilot, during cruise flight the engine rpm increased to an "over speed condition." The pilot stated that he reduced power but was unable to maintain altitude. When he increased power, he could not keep the rpm under redline and he elected to perform a forced landing. During the landing, the landing gear collapsed and folded aft. Both flap assemblies were bent up and aft. The aft spars in both wings and the false spars within the gear well area were bent.

The pilot stated they had been having difficulty obtaining full rpm from the engine. He stated that the propeller governor had been adjusted several times, but full rpm was never obtained.

On March 3, 2006, the airframe and engine were examined under the auspices of the NTSB Investigator-in-Charge (IIC) and airworthiness inspectors from the Federal Aviation Administration (FAA). Removal of the oil suction screen revealed metal contamination inside and outside the screen. Examination of the propeller governor revealed the adjustment screw had been adjusted beyond its maximum stop. The propeller governor was removed and the screen between the governor and the engine was entirely obstructed with metal contamination. Removal and examination of the oil filter revealed metal contamination.

On March 15, 2006, the engine was further examined by the NTSB IIC. A representative from Teledyne Continental Motors (TCM) and two FAA airworthiness inspectors were present during the examination. Broken portions of the number two main bearing were found within the oil sump. Breakaway torque values revealed that the number two and number three cylinder throughbolt nuts, at the cylinder flange, were loose at 500 inch/pounds. According to TCM Service Bulletin (SB) 96-7C, the cylinder through bolt nuts should be torqued to a value of 600 inch/pounds.

Disassembly of the engine revealed fretting between the crankcase halves at the number two and number three cylinder throughbolt positions. The remaining portions of number two main bearing were found around the crankshaft and fused to the number two crankshaft main bearing saddle. Further examination revealed metal contamination throughout the engine, including the oil pump and the oil cooler. No other anomalies were noted with the airframe, propeller, or engine.

The engine, airframe, and propeller logbooks were made available to the NTSB IIC for review. On November 23, 2004, at an engine tachometer time of 1,809.17, the number 4 cylinder was removed, overhauled, and replaced by Precision Aircraft & Engine Services, Inc. The logbook entry states that "all work [was] done in accordance with TCM TSIO-360 overhaul manual." On November 16, 2005, at an engine tachometer time of 1,959.37, the oil and filter were removed and replaced, and an oil sample was sent for analysis. The results from that analysis indicated "excessive wear." No propeller governor entry was noted in any of the maintenance logbooks. At the time of the accident, the engine tachometer time was 1,988.28.

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.

Airframe/component/system failure/malfunctionCruise - normal
Maintenance,installation - improperOther maintenance personnelCause
Engine assembly,bearing - shiftedCause
Propeller governor control - flow restricted
Propeller governor control - overspeed
Operation with known deficiencies in equipment - continuedPilot in commandFactor
Forced landingEmergency descent/landing
Precautionary landing - performedPilot in command
On ground/water encounter with terrain/waterEmergency landing
Terrain condition - high vegetation

Aircraft

Registration
N2939V
Reported as
Piper PA-28RT-201T
Category
Airplane
Serial number
28R-7931264
Airframe hours
3,817
Engine
Teledyne Continental TSIO-360-FB5B, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 1, 2005
Departed
FTG · Denver, CO
Destination
7V1 · Buena Vista, CO

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
35
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
May 1, 2004
Seat
Right
Flight hours
495 total · 250 in this make and model · 1 in the last 24 hours
Role
Pilot
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Seat
Left
Flight hours
315 total · 235 in this make and model · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
7 statute miles
Lowest ceiling
8,000 ft broken
Temperature
27 °F, dew point 21 °F
Altimeter
30.25 inHg
Observed at
APA, 15 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.