# NTSB ERA10LA306: Piper PA-28-180, N5118L, Lucedale, MS, June 8, 2010 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 8, 2010, 12:00 local (17:00 UTC) - Place: Lucedale, MS - Coordinates: 30.984167, -88.499725 - Nearby events: https://openairdocs.org/map.md?lat=30.9842&lon=-88.4997&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report April 7, 2011 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 76267 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA10LA306 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/76267/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=76267 - Page: https://openairdocs.org/ntsb/ERA10LA306 ## Probable cause The partial separation of the No. 3 cylinder due to improper torquing of the cylinder hold-down bolts by maintenance personnel during installation of the cylinder. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-28-180, 3 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=7102808), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Maintenance: replacement](https://openairdocs.org/ntsb-findings/02062020): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28-180, 1 case](https://openairdocs.org/ntsb-findings/02062020/cases.md?model=7102808), [All aircraft, 70 cases](https://openairdocs.org/ntsb-findings/02062020/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Maintenance personnel (probable cause); cases with it: [Piper PA-28-180, 10 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=7102808), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Piper PA-28-180, 19 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7102808), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-180, 40 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102808), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Piper PA-28-180, 5 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=7102808), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis About 20 minutes after takeoff, the pilot heard a "pop" that sounded as if it came from the engine compartment. The engine then experienced a loss of power and the pilot elected to perform a forced landing to a field, during which the airplane nosed over. A postaccident examination of the engine revealed that the No. 3 cylinder had partially separated from the engine case. Additionally, the attaching hardware was loose and the thru-bolts were broken. The cylinder had been replaced 16 flight hours prior to the accident. ## Factual narrative On June 8, 2010, about 1200 central daylight time, a Piper PA-28-180, N5118L, was substantially damaged when it nosed over during a forced landing following loss of engine power in Lucedale, Mississippi. The certificated private pilot was not injured. Visual meteorological conditions prevailed and no flight plan was filed for the flight which originated at the H L Sonny Callahan Airport (4R4), Fairhope, Alabama, and was destined for the Hattiesburg-Laurel Regional Airport (PIB), Hattiesburg, Mississippi. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. According to the pilot, prior to departure from 4R4, he performed a pre-flight inspection which included checking the oil and filling the fuel tanks to full. He departed around 1130 and estimated the flight would be about one hour in duration. About 20 minutes after departure, at an altitude of 4,500 feet, he heard a "loud pop," and then the engine began to lose power. The pilot began to smell something burning and notified the Federal Aviation Administration (FAA) Mobile Air Traffic Control facility of his emergency. He was radar vectored to a nearby airport, but shortly after realized that it was too far away and that he would be unable to make it to the airport. The pilot performed a forced landing to a field, during which the airplane nosed over. Examination of the airplane by a FAA inspector revealed substantial damage to the fuselage. Further examination of the Lycoming O-360 engine revealed the No. 3 cylinder had separated from the engine case. All of the attaching hardware was loose, and the thru-bolts were broken. No damage was observed to the valve train, piston, or cylinder interior. According to the airplane and engine logbooks, on November 13, 2009, all four cylinders were "removed and replaced with overhauled exchange chrome cylinders," at a total aircraft time of 3,231 hours. The total time at the time of the accident was 3,247 hours. The pilot held a private pilot certificate with a rating for airplane single-engine land. His most recent FAA third-class medical certificate was issued on September 29, 2009. At that time he reported 530 total hours of flight experience. The recorded weather at Mobile Regional Airport (MOB), 22 miles to the southeast, at 1156, included wind from 110 degrees at 4 knots, 10 miles visibility, few clouds at 25,000 feet, temperature 31 degrees C, dew point 19 degrees C, and altimeter setting 30.09 inches mercury. ## Aircraft - Registration: [N5118L](https://openairdocs.org/deregistered/N5118L-2012-12-11), registration cancelled 2012-12-11, S/N 28-4401, built 1967 (OpenAirDocs) - Reported make and model: PIPER PA-28-180 - Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-4401 - Airframe hours: 3247 - Engines: LYCOMING O-360 SER 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 7, 2009 - Departed: 4R4, Fairhope, AL - Destination: PIB, Hattiesburg, MS - Flight plan: VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 67; injuries: none; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review April 8, 2009; seat: left; flight hours: 590 total, 500 in this make and model, 473 as pilot in command, 25 in the last 90 days, 8 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 110° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 88 °F, dew point 66 °F - Altimeter: 30.09 inHg - Observed at: MOB, 22 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). - [Accident 20100608039619A](https://openairdocs.org/incident/20100608039619A), Jun 8, 2010: Piper PA-28-180, Lucedale, MS, Substantial damage. On June 8, 2001, N5118L, departed fairhope, AL, for hattiesburg, MS (pib). Prior to departure the fueled with 50 gallons total. Twenty minutes into the flight,… ## Docket (8 files) The files NTSB released with the investigation on January 14, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=76267. 20.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336446&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Interviews (item 2, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336546&FileExtension=.PDF&FileName=Pilot%20Interviews-Redacted.PDF - FAA Inspector Photos and Examination Notes (item 3, PPT, 12.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336523&FileExtension=ppt&FileName=FAA%20Inspector%20Photos%20and%20Examination%20Notes-Master - Recorded METAR observations (item 4, .PDF, 11 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336525&FileExtension=.PDF&FileName=Recorded%20METAR%20observations-Master.PDF - Maintenance Logbook Excerpts (item 5, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336547&FileExtension=.PDF&FileName=Maintenance%20Logbook%20Excerpts-Redacted.PDF - Annual Inspection Paperwork (item 6, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336548&FileExtension=.PDF&FileName=Annual%20Inspection%20Paperwork-Redacted.PDF - Photo 1: Aircraft at accident site (photo courtesy of FAA) (item 7, .PDF, 759 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336526&FileExtension=.PDF&FileName=Photo%201%3A%20Aircraft%20at%20accident%20site%20(photo%20courtesy%20of%20FAA)-Master.PDF - Photo 2: Aircraft right side (photo courtesy of FAA) (item 8, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336531&FileExtension=.PDF&FileName=Photo%202%3A%20Aircraft%20right%20side%20(photo%20courtesy%20of%20FAA)-Master.PDF 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.