# NTSB ERA15LA217: Piper PA-28-181, N597JG, Corryton, TN, May 19, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: May 19, 2015, 16:50 local (20:50 UTC) - Place: Corryton, TN - Coordinates: 36, -83 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.0000&lon=-83.0000&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: 2 uninjured - Status: Completed, report March 6, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - ADs cited in the narratives: [AD 2009-26-12](https://openairdocs.org/ad/2009-26-12) (OpenAirDocs) - NTSB case key (mKey): 91206 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15LA217 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91206/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91206 - Page: https://openairdocs.org/ntsb/ERA15LA217 ## Probable cause The failure of the No. 4 engine cylinder due to fatigue, resulting in a catastrophic failure of the engine. ## 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-28-181, 6 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=7102807), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-28-181, 4 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=7102807), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/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 (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-28-181, 26 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102807), [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-28-181, 23 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102807), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-flare/touchdown: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-181, 70 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102807), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis During a training flight, the student and flight instructor heard a "loud bang" from the engine area, accompanied by engine roughness and reduced power. The flight instructor performed a forced landing to a field, resulting in substantial damage to the engine firewall. An examination of the engine revealed the No. 4 cylinder head was fractured outboard of the barrel thread. Further examination revealed that the cylinder fractured due to fatigue that initiated at the interior of the head near the intake valve. The serial number for the cylinder was outside the range of those affected by an airworthiness directive requiring inspection and/or replacement of certain cylinders. ## Factual narrative On May 19, 2015, about 1650 eastern daylight time, a Piper PA-28-181, N597JG, was substantially damaged during a forced landing near Corryton, Tennessee. The student pilot and certificated flight instructor (CFI) were not injured. The airplane was registered to and operated by Knoxville Flyers Incorporated under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan had been filed for the instructional flight, which departed Knoxville Downtown Island Airport (DKX), Knoxville, Tennessee, at 1430.According to the CFI, his student was performing flight maneuvers when he heard a loud "bang" from the area of the engine. This was accompanied by engine roughness and a reduced rpm. The CFI took control of the airplane and the student pilot completed the engine restart checklist in an attempt to resolve the engine roughness. The engine continued to lose power and the airplane began losing altitude. The CFI declared an emergency and informed air traffic control that he would be conducting an off-airport landing. He then performed a forced landing in a field, and during the landing sequence the firewall was damaged. A detailed postaccidetn examination of the airplane revealed the nose gear mount attachment and firewall was buckled. No further damage was noted on the airframe. An examination of the engine revealed the No. 4 cylinder head was fractured circumferentially on the head at the outboard barrel thread. The cylinder was removed and sent to the NTSB Materials Laboratory for further examination. Detailed examination of the cylinder's fracture surfaces revealed that portion of the fracture surface had relatively smooth fracture features with curving crack arrest lines, features consistent with fatigue. Examination of the cylinder revealed that there were markings cast on the cylinder near the exhaust port opening that read ECI and AEL85099 IR. A stamp near the intake port opening read 51932-14. A review of the maintenance logbooks revealed that the engine was overhauled on February 7, 2008. On May 1, 2014, the engine had a time of 1,012.5 hours since overhaul. No anomalies were reported following a compression check performed during the annual inspection. The last engine service (oil change) prior to the accident was entered May 13, 2015, with a recorded time of 1509.7 hours since overhaul. A review of Airworthiness Directive (AD) 2009-26-12, effective February 4, 2010 required repetitive inspections or inspection and early replacement of cylinders with certain ECI part number AEL85099 heads installed on Lycoming 320, 360, and 540 series engines including the Lycoming O-360-A4M engine installed on the accident airplane. The serial number for the cylinder head in this accident was outside the range of serial numbers listed in AD 2009-26-12, and therefore was not subject to the inspection and replacement requirements. ## Aircraft - Registration: [N597JG](https://openairdocs.org/aircraft/N597JG), registered now, S/N 2843087, built 1997 (OpenAirDocs) - Reported make and model: PIPER PA-28-181 - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming 0-360-A1D](https://openairdocs.org/engine/lycoming-0-360-a1d) (registry code 41504, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2843087 - Year built: 1997 - Airframe hours: 3519.9 - Engines: LYCOMING O-360-A4M 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 1, 2015, 515 hours before - Departed: DKX, Knoxville, TN - Destination: DKX, Knoxville, TN - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 59; injuries: none; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review January 25, 2015; seat: right; restraint: 3-point; flight hours: 2,083 total, 97 in this make and model, 1,998 as pilot in command, 32 in the last 90 days, 13 in the last 30 days - Student pilot; age 42; injuries: none; student; medical: class 3, with waivers/limitations; seat: left; restraint: 3-point; flight hours: 54 total, 53 in this make and model, 5 as pilot in command, 15 in the last 90 days, 13 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 340° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: 25,000 ft broken - Temperature: 82 °F, dew point 61 °F - Altimeter: 30.03 inHg - Observed at: TYS, 12 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 20150519006579A](https://openairdocs.org/incident/20150519006579A), May 19, 2015: Piper PA-28-181, Knoxville, TN, Substantial damage. The PIC and passenger heard a loud sound (bang) come from the engine. This was accompanied by engine roughness and reduced RPM. Altitude could no longer be… ## Docket (6 files) The files NTSB released with the investigation on January 3, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91206. 5.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40447948&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Memorandum Of Record - CFI Statement (item 2, .PDF, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40447949&FileExtension=.PDF&FileName=Memorandum%20Of%20Record%20-%20CFI%20Statement-Master.PDF - Accident Photos (item 3, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40447951&FileExtension=.PDF&FileName=Accident%20Photos-Master.PDF - Materials Laboratory Factual Report 15-108 (item 4, .PDF, 474 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40447952&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report%2015-108-Master.PDF - Maintenance Records - Engine Logbook Pages (item 5, .PDF, 975 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40447954&FileExtension=.PDF&FileName=Maintenance%20Records%20-%20Engine%20Logbook%20Pages-Master.PDF - Evidence Control Form (item 6, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40447955&FileExtension=.PDF&FileName=Evidence%20Control%20Form-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.