ERA13LA097

NTSB accident investigation · Piper PA-28R-200 · Lock Haven, PA · December 23, 2012

Accident · Serious injuriesLimited investigationFinal report
Date
December 23, 2012, 13:30 local (18:30 UTC)
Place
Lock Haven, PA
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N2074TPiper PA-28R-200
Defining event
Enroute: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report September 30, 2014
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20121223027499A
Case key
85877

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 reinstallation of improper connecting rods at engine overhaul, which resulted in abnormal wear of the connecting rod bearings; while the bearings did not meet the manufacturer’s specifications, the use of the unapproved connecting rods more likely caused the bearing wear.

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 engine power sectionAircraft › Aircraft power plant · Incorrect service/maintenancePiper PA-28R-200: 8 casesAll aircraft: 233 casesProbable cause
Maintenance: unauthorized maint/repairPersonnel issues › Task performance · Maintenance personnelPiper PA-28R-200: 2 casesAll aircraft: 14 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 said the airplane was in cruise flight at 7,500 feet when the engine began to "surge" and then, shortly thereafter, stopped producing power. He selected a forced landing area in a clearing, but the airplane entered trees before reaching the clearing and came to rest upright in flat, heavily wooded terrain. Examination of the engine at the scene revealed that it could not be rotated by hand, and metal particles were contained in the oil filter and the finger strainer. Disassembly of the engine at the manufacturer's facility revealed the oil sump contained debris associated with the No. 3 connecting rod, piston, and attachment hardware. The connecting rod had fractured at the crankshaft and punctured the crankcase. The fractured end of the rod was exposed in the hole and examination revealed evidence of oil starvation at the No. 3 connecting rod journals, which resulted in the rod's separation from the crankshaft. Metallurgical examination of No. 3 bearing fragments and intact bearings harvested from the engine revealed material and construction discrepancies between the aftermarket manufacturer's parts drawings and the bearings themselves. The connecting rods used in the accident engine were not approved for installation by the engine manufacturer; however, the bearings used with the connecting rods were properly matched to the rods installed. Because the connecting rods and, therefore, the connecting rod bearings, were not the correct parts for the engine, it is probable that the bearings failed from improper part selection and, therefore, possibly improper material selection.

Factual narrative

Lycoming Service Instruction SI 1009 AU recommended overhaul at 2,000 engine hours, or at the 12th year of service whichever occurs first. According to the bulletin: "Engine deterioration in the form of corrosion (rust) and the drying out and hardening of composition materials such as gaskets, seals, flexible hoses and fuel pump diaphragms can occur if an engine is out of service for an extended period of time. Due to the loss of a protective oil film after an extended period of inactivity, abnormal wear on soft metal bearing surfaces can occur during engine start. Therefore, all engines that do not accumulate the hourly period of time between overhauls specified in this publication are recommended to be overhauled in the twelfth year." According to FAA records, the airplane was manufactured in 1970. Its most recent annual inspection was completed July 16 2012, at 3,314 total aircraft hours. The airplane had accrued 27 total aircraft hours since that date. The airplane was equipped with a Lycoming IO-360-C1C fuel-injected, horizontally opposed four-cylinder, direct-drive, air-cooled piston aircraft engine. Examination of maintenance records revealed the engine's most recent overhaul was completed by Kline Aviation Inc, Brooklyn, Michigan on September 23, 1999, and installed in the airplane February 19, 2001. The connecting rods underwent magnaflux inspection and were reinstalled. The engine had accrued 839 hours since the date of the overhaul. This was the second major overhaul of the engine. The previous major overhaul was completed by Air Craftsmen Inc., March 1, 1985. On December 23, 2012, at 1330 eastern standard time, a Piper PA-28R-200, N2074T, was destroyed when it collided with trees and terrain following a total loss of engine power in cruise flight near Lock Haven, Pennsylvania. The private pilot was seriously injured. Visual meteorological conditions prevailed, and a visual flight rules flight plan was filed for the personal flight that was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. A Federal Aviation Administration (FAA) aviation safety inspector interviewed the pilot. The pilot said the airplane was in cruise flight at 7,500 feet when the engine began to "surge" and then shortly thereafter stopped producing power. An engine restart attempt was unsuccessful, and through communication with air traffic control and crosschecking his GPS receiver, the pilot determined he was beyond gliding distance of the nearest airport. He selected a forced landing area in a clearing, but the airplane entered trees prior to the clearing and came to rest upright in flat, heavily wooded terrain. At 1354, the weather conditions reported at Williamsport-Lycoming County Airport (IPT), 25 miles southeast of the accident site, included clear skies, visibility 10 miles, temperature 3 degrees C, dewpoint -8 degrees C, and an altimeter setting of 29.87 inches of mercury. The wind was from 290 degrees at 7 knots. The pilotheld a private pilot certificate with ratings for airplane single-engine land and sea. His most recent FAA third-class medical certificate was issued on January 6, 2011. The pilot reported 548 total hours of flight experience, of which 350 hours were in the accident airplane make and model. On February 14, 2013, the engine was examined at Lycoming Engines, Williamsport, Pennsylvania. The oil sump was removed and contained debris associated with the No. 3 connecting rod, piston and attachment hardware. The connecting rod had fractured at the crankshaft and punctured the crankcase. The fractured end of the rod was exposed in the hole and examination revealed evidence of oil starvation at the No. 3 connecting rod journals, which resulted in its separation from the crankshaft. The engine crankcase was opened, and the Nos. 1, 2, and 4 connecting rod bearings, and the No. 3 bearing remnants, were removed from the crankshaft and crankcase, and forwarded to the NTSB Materials Laboratory in Washington, DC for examination. The intact bearing halves exhibited signs of abnormal wear, delamination, and areas of "pick out." Metallurgical Exam The connecting rod bearings (P/N 13212-M03) were manufactured by Superior Air Parts in Dallas, Texas. Examination of the part drawings from Superior for the connecting rod bearings revealed material and construction discrepancies between the drawings and the bearings harvested from the engine. The intact bearings all exhibited signatures consistent with fatigue and spalling of the babbitt material, which exposed the steel backing. The part numbers for the bearings were the correct application for the connecting rods; however, examination of the connecting rods (LW-13422) revealed that they were not approved by Lycoming engines for installation in the IO-360-C1C. The wreckage was examined at the accident site by an FAA aviation safety inspector on December 23, 2012, and all major components were accounted for at the scene. Both wings were separated during the accident sequence and scattered along the wreckage path. The elevator and vertical fin were impact damaged, but still attached. Rescue personnel removed the cabin roof. A preliminary examination of the engine revealed that it could not be rotated by hand, and metal particles were contained in the oil filter and the finger strainer. The engine examination was suspended, and a detailed examination of the engine was scheduled for a later date.

Aircraft

Registration
N2074T
Reported as
Piper PA-28R-200
Category
Airplane
Serial number
28R-7135018
Airframe hours
3,314
Engine
Lycoming IO-360 SER, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Aero Too Inc
Registered owner
Aero Too Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 16, 2012
Departed
UCP · New Castle, PA
Destination
20N · Kingston, NY
Flight plan
VFR

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
60
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine sea, Single-engine land
Medical
Class 3, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
548 total · 350 in this make and model · 470 as pilot in command · 19 in the last 90 days · 10 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
39 °F, dew point 18 °F
Altimeter
29.85 inHg
Observed at
IPT, 25 nm away

Docket · 10

The files NTSB released with the investigation on August 13, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 21.4 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 N2074T · 2

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