ERA10LA021

NTSB accident investigation · Palen AVRO-504K · Rhinebeck, NY · October 17, 2009

Accident · No injuriesLimited investigationFinal report
Date
October 17, 2009, 15:05 local (19:05 UTC)
Place
Rhinebeck, NY
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N4929Palen AVRO-504K
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report July 22, 2010
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20091017050339A
Case key
74922

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

On this page

Probable cause

A loss of engine power due to the in-flight separation of the number 3 cylinder valve rocker arm attachment hardware. Contributing to the accident was the improper maintenance inspection of the engine.

Findings · 3

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 · MalfunctionPalen AVRO-504K: 1 caseAll aircraft: 373 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelPalen AVRO-504K: 1 caseAll aircraft: 320 casesProbable cause
Maintenance/inspections: scheduled maint checksAircraft › Aircraft handling/service · Inadequate inspectionPalen AVRO-504K: 1 caseAll aircraft: 76 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

The pilot was performing an aerial demonstration for spectators. Shortly after takeoff, he heard a “thump,” the engine lost power, and he performed a forced landing in trees. Post-accident inspection of the wreckage revealed a keeper and cotter pin that connects the push rod to the number 3 cylinder valve rocker arm was missing. The high-tension spark plug lead to the number 5 cylinder was severed. The pilot, who also maintains the aircraft, believes the flailing spark plug lead flew into the commutator ring, shorting out other cylinders and leading to a total power loss. The missing hardware from the number 3 cylinder was never recovered. According to maintenance records, the airplane received a condition inspection on September 22, 2009. During that inspection, the number 5 cylinder was removed for repair and reinstalled, and the other rocker arms and valve springs were inspected.

Factual narrative

On October 17, 2009, about 1505 eastern daylight time, an experimental Palen Avro-504K, N4929, was substantially damaged after a loss of engine power and forced landing near the Old Rhinebeck Airport (NY94), Rhinebeck, New York. The exhibition airplane was owned and operated by the Rhinebeck Aerodrome Museum. The commercial pilot was not injured. Visual meteorological conditions prevailed at the time, and no flight plan was filed for the 14 Code of Federal Regulations Part 91 air show flight. The flight was originating at the time of the accident. The pilot reported that approximately 200 feet above ground level after takeoff, a “thump” was heard from the engine. He did not have sufficient runway in front of him for landing, so he turned to the right, away from the spectator line. The engine was losing power, so he attempted to maintain flying speed and set up for a landing on the runway. While turning base leg for runway 10, the engine continued to lose power and the pilot was forced to set the airplane down in the trees. He estimated the airspeed to be 35 to 40 knots when the airplane contacted the trees. An inspector from the Federal Aviation Administration (FAA) inspected the airplane following the accident. The wings sustained structural damage from contact with the trees. Examination of the Le Rhone 9-cylinder radial engine revealed that a push/pull rod that operates the number 3 cylinder intake and exhaust valves was disconnected. A keeper and cotter pin that connects the push rod to the valve rocker arm was missing. The missing parts were not located after a search of the accident site. The pilot, who also maintained the airplane, reported that his inspection of the wreckage revealed a high-tension lead on the number 5 cylinder spark plug was severed, presumably from being struck by the hardware that liberated from the number 3 cylinder. He added that, the “high tension lead broke free of [the] spark plug and flew into [the] commutator ring, shorting out more cylinders causing the engine to fail completely.” According to maintenance records, the airplane received a condition inspection on September 22, 2009. During that inspection, the number 5 cylinder was removed for repair and reinstalled, and the other rocker arms and valve springs were inspected. The 1453 weather observation for Poughkeepsie, New York (POU), located 20 nautical miles south of the accident site, included the following: few clouds at 7,500 feet, surface winds from 360 degrees at 7 knots, 10 statute miles visibility, temperature 9 degrees Celsius, dew point 0 degrees Celsius, and an altimeter setting of 30.08 inches of mercury.

Aircraft

Registration
N4929
Reported as
Palen AVRO-504K
Category
Airplane
Serial number
HAC1
Airframe hours
207
Engine
Lerhone TYPE C, 80 horsepower, reciprocating
Damage
Substantial damage
Flight
Air race/show · Part 91
Operator
Rhinebeck Aerodrome Museum
Registered owner
Rhinebeck Aerodrome Museum
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · September 22, 2009 · 6 hours before
Departed
NY94 · Rhinebeck, NY
Destination
NY94 · Rhinebeck, NY
Airport
NY94 · Old Rhinebeck Airport, runway 18, 2,200 × 75 ft, dirt

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
50
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 2, With waivers/limitations
Last flight review
February 22, 2007
Seat
Single
Flight hours
4,200 total · 20 in this make and model · 4,200 as pilot in command · 63 in the last 90 days · 30 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
360° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
48 °F, dew point 32 °F
Altimeter
30.07 inHg
Observed at
POU, 20 nm away

Docket · 5

The files NTSB released with the investigation on May 5, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.3 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.

Other investigations on N4929 · 1

Matched to the same aircraft by N-number and date.