# NTSB ERA14LA042: Piper PA28, N1830T, Homestead, FL, November 11, 2013 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: November 11, 2013, 08:30 local (13:30 UTC) - Place: Homestead, FL - Coordinates: 25.444999, -80.87889 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=25.4450&lon=-80.8789&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report January 21, 2016 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 88415 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14LA042 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88415/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88415 - Page: https://openairdocs.org/ntsb/ERA14LA042 ## Probable cause A total loss of engine power due to the in-flight separation of the No. 3 cylinder because of the fatigue cracking of its respective mounting studs and through bolts, which resulted from inadequate maintenance by unknown personnel. ## 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 · Failure (probable cause); cases with it: [Piper PA-28-140, 6 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=7102802), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Other (probable cause); cases with it: [Piper PA-28-140, 9 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=7102802), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Maintenance/inspections](https://openairdocs.org/ntsb-findings/01010500): Aircraft › Aircraft handling/service · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-28-140, 1 case](https://openairdocs.org/ntsb-findings/01010500/cases.md?model=7102802), [All aircraft, 103 cases](https://openairdocs.org/ntsb-findings/01010500/cases.md) - [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-28-140, 6 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=7102802), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Terrain: water](https://openairdocs.org/ntsb-findings/03021020): Environmental issues › Physical environment · Not specified; cases with it: [Piper PA-28-140, 2 cases](https://openairdocs.org/ntsb-findings/03021020/cases.md?model=7102802), [All aircraft, 97 cases](https://openairdocs.org/ntsb-findings/03021020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Piper PA-28-140, 12 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=7102802), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-28-140, 42 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102802), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-140, 56 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102802), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-140, 137 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102802), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The student pilot reported that the airplane was in cruise flight at 5,500 ft mean sea level when the engine began to vibrate. Shortly after, the engine "began coming apart" with pieces striking the underside of the cowling, indicative of a catastrophic failure. The student pilot performed a forced landing to a swampy area. The airplane came to rest in shallow water and sustained substantial fuselage damage. Examination of the engine revealed that the No. 3 cylinder had separated from the crankcase. During subsequent examination, both through bolts and three of the four remaining cylinder studs were also found fractured, and the fracture surfaces were consistent with fatigue cracking, likely due to insufficient application of torque on the through bolts during installation or the loss of torque in the through bolts. Additionally, unapproved room temperature vulcanization-type material found on the crankcase halves could have contributed to a loss of torque on the through bolts, but a definitive determination could not be made. The engine was overhauled about 28 years before the accident, and it had been operated for about 1,050 total hours since the overhaul. The airplane's most recent annual inspection was performed about 8 months before the accident, and it had been operated about 230 hours since the inspection. Available maintenance records did not reveal any in-service cylinder replacements or reinstallations. ## Factual narrative On November 11, 2013, about 0830 eastern standard time, a Piper PA-28-140, N1830T, operated by a private individual, was substantially damaged during a forced landing, after it experienced a total loss of engine power while in cruise flight near Homestead, Florida. The student pilot was not injured. Visual meteorological conditions prevailed and a visual flight rules flight plan had been filed for the flight that departed Key West International Airport, Key West, Florida, destined for the Sarasota-Bradenton International Airport, Sarasota, Florida. The instructional flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.The student pilot owned and operated the airplane. He reported that the airplane was at an altitude of 5,500 feet mean sea level, when he felt a slight engine vibration. All engine gauges remained normal; however, the vibration began to increase and the student pilot elected to divert to the Homestead General Aviation Airport, Homestead, Florida. Shortly thereafter, the engine "began coming apart" with pieces striking the underside of the cowling. The student pilot subsequently performed a forced landing to Everglades National Park. The airplane came to rest in shallow water and sustained substantial fuselage damage. The airplane was equipped with a Lycoming O-360-A1A, 180-horsepower engine. Initial examination of the airplane by a Federal Aviation Administration inspector revealed that the No. 3 cylinder had separated from the crankcase. The airplane was recovered from the accident site about 1 year after the accident and subsequently examined by an NTSB investigator. The crankshaft and valve train were seized and could not be rotated by hand. A large breach in the crankcase was noted above the No. 3 cylinder mount pad, and the upper portion of the mount pad, which included two cylinder studs, was missing. The No. 3 cylinder connecting rod remained attached to the crankshaft and moved freely. The piston pin portion of the No. 3 cylinder connecting rod was fractured. The crankcase and No. 3 connecting rod were forwarded to the NTSB Materials Laboratory, Washington, DC for further examination. Examination of the retained engine parts by an NTSB metallurgist revealed that in addition to the crankcase fracture at the No. 3 cylinder attachment area, both through bolts, and three of the four remaining cylinder studs were fractured. The crankcase and No. 3 connecting rod fractures were typical of overstress separations; however, the three cylinder studs, and two through bolts contained fractures consistent with fatigue fractures. Light fretting wear scars were noted on the main bearing boss surfaces between the forward and aft cylinders, and the bearing bosses at the forward through bolts. Light fretting wear was also noted adjacent to the middle bearing boss for the camshaft. The outer surfaces of the parting crankcase halves displayed thin reddish sealant material. The material appeared consistent with aroom-temperature-vulcanizing (RTV) material. According to the applicable Lycoming engine overhaul manual, the parting surfaces of the crankcase halves were to be sealed by applying "a film of non-hardening gasket compound" to certain surfaces and imbedding a length of "00" silk thread into the gasket material on one side of the case. Lycoming Service Instruction 1125D, dated October 17, 2008, provided instructions for "Alternate Crankcase Parting Surface Sealant," and identified two approved alternate sealant materials, which were white and dark purple in color. [Additional information can be found in Materials Laboratory Factual Report No. 15-057 located in the public docket.] According to maintenance records, the engine was overhauled and installed on the accident airplane on March 15, 1985. Available maintenance records did not reveal any in service cylinder replacements or reinstallations. At the time of the accident, the engine had been operated for about 1,050 total hours since overhaul, and about 230 hours since its most recent annual inspection, which was performed on March 1, 2013. ## Aircraft - Registration: [N1830T](https://openairdocs.org/deregistered/N1830T-2018-02-28), registration cancelled 2018-02-28, S/N 28-7125231, built 1971 (OpenAirDocs) - Reported make and model: PIPER PA28 (140) - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7125231 - Year built: 1971 - Engines: LYCOMING O-360-A1A 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 1, 2013, 230 hours before - Departed: EYW, KEY WEST, FL - Destination: SRQ, SARASOTA/BRADENTON, FL - Flight plan: VFR - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Student pilot; age 46; injuries: none; student; medical: class 3, with waivers/limitations; seat: left; flight hours: 179 total, 179 in this make and model, 40 as pilot in command, 87 in the last 90 days, 8 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 20° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 75 °F, dew point 70 °F - Altimeter: 30.07 inHg - Observed at: HST, 25 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 20131111023569A](https://openairdocs.org/incident/20131111023569A), Nov 11, 2013: Piper PA-28-140, Homestead, FL, Substantial damage. On a flight from key west Florida to sarasota Florida the aircraft experienced loss of thrust due to engine failure. The pilot performed an emergency landing… ## Other investigations on N1830T (1) 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. - [NTSB NYC76DHD40](https://openairdocs.org/ntsb/NYC76DHD40), Aug 21, 1976: Piper PA-28 (N1830T), Berlin, NJ, substantial damage ## Docket (6 files) The files NTSB released with the investigation on December 4, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88415. 4.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434500&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot's Statement (item 2, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434501&FileExtension=.PDF&FileName=Pilot%27s%20Statement-Master.PDF - Materials Laboratory Factual Report 15-057 (item 3, .PDF, 787 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434502&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report%2015-057-Master.PDF - Maintenace Record Excerpts (item 4, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434503&FileExtension=.PDF&FileName=Maintenace%20Record%20Excerpts-Master.PDF - Evidence Control Form (item 5, .PDF, 242 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434504&FileExtension=.PDF&FileName=Evidence%20Control%20Form%20-Master.PDF - Accident Photographs (item 6, .PDF, 918 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434505&FileExtension=.PDF&FileName=Accident%20Photographs-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.