ERA09LA261

NTSB accident investigation · Piper PA-28R-200 · Hilliard, FL · April 23, 2009

Accident · No injuriesLimited investigationFinal report
Date
April 23, 2009, 15:00 local (19:00 UTC)
Place
Hilliard, FL
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N2938RPiper PA-28R-200
Defining event
Enroute-change of cruise level: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report April 22, 2010
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20090423007619A
Case key
73719

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

A total loss of engine power due to the fatigue failure of the No. 3 cylinder attachment stud as a result of insufficient torque during installation. Contributing to the accident was the pilot’s operation of the airplane with a known mechanical deficiency.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · Fatigue/wear/corrosionPiper PA-28R-200: 4 casesAll aircraft: 373 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelPiper PA-28R-200: 4 casesAll aircraft: 371 casesProbable cause
Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · Incorrect service/maintenancePiper PA-28R-200: 4 casesAll aircraft: 373 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

Approximately 2 hours into the cross-country flight the pilot heard a loud noise from the engine compartment and the engine subsequently failed. The pilot performed a forced landing in a field and the empennage struck a tree, resulting in substantial airframe damage. Examination of the engine revealed that the No. 3 cylinder partially separated in flight, resulting in the engine failure. An engine cylinder attachment stud and nut were found at the run-up pad at the departure airport. Examination of the stud revealed evidence of fatigue cracking, which was indicative of an under torque condition. Other cylinder attachment nuts on the engine showed evidence of under torquing. The pilot had recently purchased the airplane and the seller reported that an oil leak was noted during the "pre-buy" inspection. The mechanic who inspected the airplane at the pre-buy reported that two cylinders were leaking oil. The seller installed the cylinders as part of a major overhaul that occurred approximately 131 hours prior to the accident. The pilot did not have maintenance performed to address the cylinder oil leaks prior to the accident.

Factual narrative

On April 23, 2009, about 1500 eastern daylight time, a Piper PA-28R-200, N2938R, was substantially damaged following a forced landing and impact with a tree near Hilliard, Florida. The airplane was registered to and operated by the pilot. The certificated private pilot and three passengers were not injured. Visual meteorological conditions prevailed at the time, and no flight plan was filed for the 14 Code of Federal Regulations Part 91 personal flight. The flight originated at the Dallas Bay Sky Park Airport (1A0), Chattanooga, Tennessee, at 1245. The pilot reported that the flight to Winter Haven, Florida, was uneventful until in the vicinity of Hilliard, Florida. While gradually climbing to 9,500 feet mean sea level, he heard a "loud bang" in the engine compartment. The propeller started to slow and he contacted Jacksonville Center for assistance. The pilot requested the nearest airfield, and Jacksonville Center provided vectors to Hilliard Airpark (01J), Hilliard, Florida. The engine came to a complete stop and the pilot was unable to glide to 01J. The pilot selected an area for a forced landing. During the landing, the tail of the airplane collided with a tree, separating it from the fuselage. After the airplane came to a stop, the pilot removed the engine cowl and he observed one of the cylinders had separated from the crankcase. An inspector from the Federal Aviation Administration (FAA) visited the accident site and examined the wreckage. He reported that there was sufficient fuel in both fuel tanks. The No. 3 cylinder was separated from the crankcase, the corresponding connecting rod was separated from the crankshaft, and the cylinder attachment studs were broken. There was structural damage to the empennage. After the wreckage was recovered to a salvage facility, the engine was again examined. An FAA inspector found that the nuts on four engine cylinder through bolts and two cylinder attachment studs had "torque values lower then [sic] what is called for by the engine technical manual." The pilot later reported that an airport employee at the departure airport found a broken engine cylinder attachment stud and nut on the ground at the engine run-up area. The pilot forwarded the parts to the NTSB investigator-in-charge (IIC) for examination. The cylinder stud and attachment bolt were sent to the NTSB Materials Laboratory for examination. Bench binocular microscope examination of the fractured portion of the cylinder stud revealed the fracture face contained crack arrest marks typical of fatigue cracking that emanated from multiple origins at the root portion of the threads. The origin of the fatigue cracks contained no evidence of corrosion or mechanical damage. The pilot purchased N2938R on December 5, 2008. According to the maintenance records, the previous owner, who was also a certificated airframe and powerplant mechanic, performed a major overhaul of the engine per a logbook entry dated July 8, 2008. The previous owner reportedthat he installed the cylinders as part of the major overhaul and used a calibrated torque wrench during the installation. At the time of the accident, the airplane had been operated approximately 131 hours since the engine overhaul. The pilot reported that the only maintenance performed on N2938R, after the airplane was delivered to him, was the replacement of an engine starter ring gear. The previous owner reported in a telephone interview that he delivered the airplane to the pilot in December, 2008. During the sale transaction, he reported that the pilot had a mechanic present to perform a pre-buy inspection of the airplane. The mechanic noted a suspect oil leak on the right, rear cylinder (the cylinder closest to the front passenger seat). The mechanic recommended removing and replacing the cylinder base o-ring and the buyer was adamant that this repair be made prior to the sale. The previous owner stated that he paid for the repair by an adjustment to the sales price of the airplane. He did not observe the repair. He later provided a copy of the aircraft purchase agreement that had the following hand-written note at the bottom of the first page: "On delivery of Aircraft, purchasers mechanic found signs of an oil leak @ cylinder bases and recommended replacing seals. Seller agreed to pay $250.00 to have purchasers mechanic replace cylinder o-rings." The mechanic, who assisted the pilot with a pre-buy inspection of N2938R, was interviewed by the NTSB IIC by telephone. He recalled that two engine cylinders were leaking oil around the bases of the cylinders, however he could not recall which cylinders they were. He did not recall anything else remarkable about the condition of the airplane. He advised the pilot that the leaking cylinders would have to be removed to repair the leaks and that he should "talk the guy down five or six hundred dollars" on the sales price of the airplane. He also advised the seller of the cylinder leaks. He stated that the seller responded with, “All engines leak a little bit.” He stated that he then told the seller that a newly-overhauled engine should not leak oil. The 1456 weather observation for Jacksonville, Florida (JAX), located about 16 miles southeast of the accident site, included the following: few clouds at 4,000 feet, scattered clouds at 18,000 feet, surface winds from 280 degrees at 8 knots with gusts to 15 knots, 10 statute miles visibility, temperature 30 degrees Celsius, dew point 12 degrees Celsius, and an altimeter setting of 30.17 inches of mercury.

Aircraft

Registration
N2938R
Reported as
Piper PA-28R-200
Category
Airplane
Serial number
28R-35333
Airframe hours
3,661
Engine
Lycoming IO-360-C1C, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Garrison Chadrick
Registered owner
Garrison Chadrick
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 12, 2008 · 131 hours before
Departed
1A0 · Chattanooga, TN
Destination
GIF · Winter Haven, FL
Airport
01J · Hilliard Airpark, runway 18, 3,365 × 125 ft, grass/turf

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
32
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
November 2, 2007
Seat
Left
Flight hours
130 total · 26 in this make and model · 30 as pilot in command · 30 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 8 knots, gusting 15
Visibility
10 statute miles
Temperature
86 °F, dew point 54 °F
Altimeter
30.17 inHg
Observed at
JAX, 16 nm away

Docket · 13

The files NTSB released with the investigation on February 18, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.3 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.