ERA15LA377

NTSB accident investigation · Piper PA 28RT-201T · Dawson Springs, KY · September 29, 2015

Accident · Serious injuriesLimited investigationFinal report
Date
September 29, 2015, 11:00 local (16:00 UTC)
Place
Dawson Springs, KY
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N2175KPiper PA 28RT-201T
Defining event
Enroute-cruise: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report August 1, 2016
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Continental Motors
FAA report
20150929023429A
Case key
92088

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 fatigue failure of a crankshaft counterweight, which resulted in a total loss of engine power during cruise flight.

Findings · 1

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 · Fatigue/wear/corrosionPiper PA-28RT-201T: 2 casesAll aircraft: 233 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 private pilot of the single-engine airplane was conducting an instrument flight rules flight. The pilot reported that, when the airplane was in cruise flight at 7,000 ft mean sea level, he heard two loud bangs, followed by a total loss of engine power, pieces of the engine exiting the cowling, and oil covering the windscreen. The pilot attempted to divert to another airport; however, after descending through a low cloud layer, he could not visually locate the turf runway, so he performed a forced landing to a field. Teardown examination of the engine revealed that a rear crankshaft counterweight had separated and that the adjacent (No. 2) connecting rod had separated at the connecting rod bolts. Metallurgical examination of the counterweight revealed fatigue cracking that had originated at the counterweight aft blade surface near a bushing hole, consistent with a loose bushing moving in the hole over a prolonged period of time. A review of maintenance records revealed that the engine had been operated for about 1,130 hours since its last overhaul, which was completed about 19 years before the accident; the engine was 7 years beyond the 12-year recommended time between overhaul (TBO). The engine manufacturer had previously issued a service bulletin, which included a warning that the improper installation of bushings during overhaul could cause engine failure. Although the failure mode evidence was consistent with a loose bushing, it was not likely due to improper installation given that the engine had operated for almost 7 years beyond its 12-year recommended TBO. If the engine had been overhauled at the recommended time, all of the bushings would have been required to be replaced with new bushings.

Factual narrative

On September 29, 2015, about 1100 central daylight time, a Piper PA-28RT-201T, N2175K, operated by a private individual, was substantially damaged during a forced landing to a field, following a total loss of engine power during cruise flight near Dawson Springs, Kentucky. The private pilot was seriously injured. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the planned flight to Owensboro Airport (OWB), Owensboro, Kentucky. The flight originated from Foley Municipal Airport (5R4), Foley, Alabama, about 0730.The pilot reported that while in cruise flight at 7,000 feet mean sea level (msl), he heard a loud bang and the engine began to run rough. He declared an emergency to air traffic control (ATC); after which, another bang was heard and the engine lost all power. Additionally, pieces of the engine exited the cowling and oil flowed onto the windscreen. With the assistance of ATC, the pilot attempted to divert to runway 36 at Tradewater Airport (8M7), Dawson Springs, Kentucky; however, after descending through a cloud layer at 1,800 feet msl, the pilot could not locate the turf runway and elected to perform a forced landing to a field. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that it came to rest upright against a small tree, in a field about 1 mile west of 8M7. The inspector observed damage to both wings and the fuselage. The airplane was equipped with a Continental Motors TSIO-360 engine. A hole was observed in the top rear of the engine crankcase, near the No. 2 cylinder. Subsequent teardown examination of the engine revealed that a rear crankshaft counterweight had separated and the adjacent (No. 2) connecting rod also separated at the connecting rod bolts. Metallurgical examination of the counterweight revealed fatigue cracking with an origin at the counterweight aft blade surface near a bushing hole. Marks on the bushing hole were consistent with loose bushing movement over a period of time. Review of maintenance records and information provided by the pilot revealed that the engine had been operated for about 80 hours since its most recent annual inspection, which was completed on November 4, 2014. At that time, the engine had accumulated 1,049 hours since its last overhaul, which was completed on January 4, 1997. Continental Motors service bulletin M93-4 provided information about crankshaft counterweights at overhaul and included: "…Removing and replacing bushings with makeshift tools can result in damage to the crankshaft and counterweights. A special tool for removing and replacing the bushings is supplied…WARNING…Improper installation of the bushings, retaining plates or retaining rings will cause engine failure…" In addition, Continental Motors also published a service information letter (SIL) that provided information regarding timelimits between major overhauls. For the make and model engine, the SIL recommended 1,800 hours of operation or 12 years, which ever occurred first. Madisonville Regional Airport (2I0), Madisonville, Kentucky, was located about 16 miles northeast of the accident site. The recorded weather at 2I0, at 1055, was: wind from 100 degrees at 4 knots; visibility 5 miles in light rain; scattered clouds at 1,900 feet; broken ceiling at 3,700 feet; overcast ceiling at 4,400 feet; temperature 22 degrees C; dew point 22 degrees C; altimeter 29.90 inches Hg.

Aircraft

Registration
N2175K
Reported as
Piper PA 28RT-201T
Category
Airplane
Serial number
28R-7931028
Built
1978
Airframe hours
4,785
Engine
Cont Motor TSIO-360-FB, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 4, 2014 · 81 hours before
Departed
5R4 · Foley, AL
Destination
OWB · Ownesboro, KY
Flight plan
IFR
Airport
8M7 · Tradewater Airport, runway 36, 2,875 × 80 ft, grass/turf
Equipment
Stall warning system, Auto-pilot, Electronic flight bag or handheld device, Handheld GPS

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
58
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
October 24, 2013
Seat
Left
Restraint
3-point
Flight hours
630 total · 475 in this make and model · 600 as pilot in command · 27 in the last 90 days · 15 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 4 knots
Visibility
5 statute miles
Lowest ceiling
3,700 ft broken
Temperature
72 °F, dew point 72 °F
Altimeter
29.89 inHg
Observed at
2I0, 16 nm away

Docket · 8

The files NTSB released with the investigation on June 14, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.4 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.