# NTSB ERA15LA377: Piper PA 28RT-201T, N2175K, Dawson Springs, KY, September 29, 2015 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: September 29, 2015, 11:00 local (16:00 UTC) - Place: Dawson Springs, KY - Coordinates: 37.185832, -87.675003 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.1858&lon=-87.6750&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report August 1, 2016 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Continental Motors - NTSB case key (mKey): 92088 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15LA377 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92088/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92088 - Page: https://openairdocs.org/ntsb/ERA15LA377 ## Probable cause The fatigue failure of a crankshaft counterweight, which resulted in a total loss of engine power during cruise flight. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Fatigue/wear/corrosion (probable cause); cases with it: [Piper PA-28RT-201T, 2 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=7102817), [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: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Piper PA-28RT-201T, 3 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=7102817), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Piper PA-28RT-201T, 2 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102817), [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-28RT-201T, 3 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102817), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28RT-201T, 3 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102817), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N2175K-2018-03-01), registration cancelled 2018-03-01, S/N 28R-7931028, built 1978 (OpenAirDocs) - Reported make and model: PIPER PA 28RT-201T - Registry model: [Piper PA-28RT-201T](https://openairdocs.org/model/piper-pa-28rt-201t) (registry code 7102817) (OpenAirDocs) - Registry engine: [Continental TSIO-360 series](https://openairdocs.org/engine/continental-tsio-360-series) (registry code 17019, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7931028 - Year built: 1978 - Airframe hours: 4785 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: serious; 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 ## 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 20150929023429A](https://openairdocs.org/incident/20150929023429A), Sep 29, 2015: Piper PA-28RT-201T, Dawson Springs, KY, Substantial damage. Pilot stated at cruise, he "heard a loud bang" and the engine became rough. Pilot declared emergency with ATC. Diverted to 8M7, could not make the airport and… ## Docket (8 files) The files NTSB released with the investigation on June 14, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92088. 6.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 755 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441325&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Engine Manufacturer's Metallurgical Report (item 2, .PDF, 18 photos, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441326&FileExtension=.PDF&FileName=Engine%20Manufacturer%27s%20Metallurgical%20Report-Master.PDF - Engine Manufacturer Service Bulletin (item 3, .PDF, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441327&FileExtension=.PDF&FileName=Engine%20Manufacturer%20Service%20Bulletin-Master.PDF - Engine Manufacturer Service Information Letter (item 4, .PDF, 230 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441328&FileExtension=.PDF&FileName=Engine%20Manufacturer%20Service%20Information%20Letter-Master.PDF - Excerpts from Maintenance Records (item 5, .PDF, 529 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441329&FileExtension=.PDF&FileName=Excerpts%20from%20Maintenance%20Records-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 6, .PDF, 368 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441330&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Evidence Control Form (item 7, .PDF, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441331&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Master.PDF - Photo Array (item 8, .PDF, 6 photos, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441332&FileExtension=.PDF&FileName=Photo%20Array-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.