# NTSB ERA16LA053: Piper PA-32, N5568J, Opa Locka, FL, December 1, 2015 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: December 1, 2015, 10:37 local (15:37 UTC) - Place: Opa Locka, FL - Coordinates: 25.897222, -80.089164 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=25.8972&lon=-80.0892&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 3 serious - Status: Completed, report May 1, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 92382 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16LA053 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92382/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92382 - Page: https://openairdocs.org/ntsb/ERA16LA053 ## Probable cause Maintenance personnel's inadequate inspection of the exhaust system, which resulted in the escape of exhaust gases into the engine compartment and a subsequent total loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-32-260, 1 case](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=7103206), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md) - [Engine exhaust](https://openairdocs.org/ntsb-findings/01057800): Aircraft › Aircraft power plant · Inadequate inspection (probable cause); cases with it: [Piper PA-32-260, 1 case](https://openairdocs.org/ntsb-findings/01057800/cases.md?model=7103206), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/01057800/cases.md) - [Engine exhaust](https://openairdocs.org/ntsb-findings/01057800): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-32-260, 1 case](https://openairdocs.org/ntsb-findings/01057800/cases.md?model=7103206), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/01057800/cases.md) - [Engine exhaust](https://openairdocs.org/ntsb-findings/01057800): Aircraft › Aircraft power plant · Fatigue/wear/corrosion (probable cause); cases with it: [Piper PA-32-260, 1 case](https://openairdocs.org/ntsb-findings/01057800/cases.md?model=7103206), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/01057800/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150); cases with it: [Piper PA-32-260, 3 cases](https://openairdocs.org/ntsb-events/150/sequence.md?model=7103206), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-32-260, 12 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7103206), [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-32-260, 19 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7103206), [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-32-260, 30 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103206), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The private pilot stated that the airplane was climbing through about 800 ft after takeoff when light smoke appeared from the instrument panel and windscreen area. The pilot began a turn back toward the airport, and, almost immediately, the engine experienced a total loss of power. The pilot performed an off-airport forced landing, the airplane struck a parked tractor-trailer, and came to rest inverted on a berm. Subsequent examination of the airplane revealed soot and char marks on the left side of the engine cowling and in the engine compartment. The muffler's left sidewall displayed metal erosion and a wall breach that allowed exhaust gas to leak into the engine compartment. The engine fuel lines exhibited thermal damage but were not compromised. The front of the carburetor was charred, and some magneto leads were burned. The exact means by which the engine lost power could not be determined, but the intense heat of the exhaust gas could have burned off fuel in the carburetor, created a vapor lock in the fuel lines, or interrupted spark to the cylinders. Further examination of the muffler revealed that the right sidewall was thin and rusted and had small erosion holes. The accident occurred less than 8 hours of operation after the airplane's most recent annual/100-hour inspection. Manufacturer-mandated inspection criteria required particular attention be paid to the exhaust system, especially fatigue-prone areas such as the muffler sidewalls. Given the degree of preexisting deterioration noted, it is likely that the exhaust system was not properly inspected during the last inspection. ## Factual narrative On December 1, 2015, at 1037 eastern standard time, a Piper PA-32-260, N5568J, was substantially damaged during a forced landing shortly after taking off from Opa Locka Executive Airport (KOPF), Miami, Florida. The private pilot and two passengers sustained serious injuries. Visual meteorological conditions prevailed, and a visual flight rules flight plan had been filed for the flight to South Bimini Airport (MYBS), South Bimini, The Bahamas. The personal flight was operating under the provisions of 14 Code of Federal Regulations Part 91.According to the pilot, as the airplane was climbing through about 800 feet, the front seat passenger asked him if he smelled something. The pilot stated that he did and they both then saw "light smoke up around the dash and windshield area." The pilot commenced a turn back toward the airport, and almost immediately, the engine experienced a total loss of power. The pilot advised the airport tower controller of the problem, but realizing that the airplane could not make it back to the airport, performed a forced landing off-airport. According to the responding Federal Aviation Administration (FAA) inspector, the airplane first touched down on top of a parked tractor trailer, bounced over a canal, and came to rest upside down on a berm. The airplane was recovered to a storage facility where it was subsequently examined with NTSB oversight. There, soot and char marks, along with thermal damage, were noted on the left side of the cowling, both on the engine compartment side and the external side. The left (pilot) side wall of the muffler exhibited metal erosion and was fractured completely around the area where the combined cylinder exhaust pipe attached to the muffler. There were also fractures and bent metal consistent with impact damage. In addition, there was dark staining in the area of the fractures, inboard to cover about 50% of the top of the muffler. Dark staining was additionally noted on the combined cylinder exhaust pipe, most notably near the muffler, and also on the No. 2 (left side, most forward) cylinder intake riser, particularly just above and facing the combined cylinder exhaust pipe. In addition, the valve covers on the left side of the engine displayed thermal darkening on the lower portions of the covers. The engine fuel lines exhibited thermal damage, but were not compromised. The front of the carburetor was charred. The ignition wires on the left side of the engine were charred, with most having lost sections of insulation. Engine crankshaft continuity and cylinder compression were confirmed. The right side wall of the muffler was also stained, and the metal was thin and rusted, with small erosion holes. According to airplane engine and airframe logbooks, the Lycoming O-540E4B5 engine underwent a major overhaul in December 2002, and its installation on the airframe was noted on December 18, 2002, at 0 hours tachometer time. On January 11, 2005, at 122.6 hours tachometer time, the exhaustgaskets were replaced and new hardware was installed. According to the airframe logbook, the airplane's most recent annual/100-hour inspection was completed on June 17, 2015, at 468.8 hours tachometer time. The same mechanic had completed the last three annual/100-hour inspections; no exhaust system anomalies were noted during those inspections. The accident occurred at 476.0 tachometer hours. According to the Piper PA-32-260/300 Service Manual, "A very thorough inspection of the entire exhaust system, including heat exchange shroud, muffler, muffler baffles, stack and all exhaust connections must be accomplished at each 100 hour inspection." (The service manual also described how to inspect the exhaust system and alternative means to inspect it. It also provided a figure that showed typical muffler fatigue areas that included the muffler side walls. FAA Advisory Circular (AC) 91-59A, "Inspection and Care of General Aviation Aircraft Exhaust Systems" emphasizes "the safety hazards of poorly maintained aircraft exhaust systems (reciprocating powerplants) and highlights points at which exhaust system failures occur. Further, it provides information on the kinds of problems to be expected and recommends pilots perform ongoing preventive maintenance and mechanics perform maintenance." The AC also notes that potential failures can include leakage of exhaust gas into the cabin, partial or full engine power loss, or impingement heating or torching of surrounding structures. ## Aircraft - Registration: [N5568J](https://openairdocs.org/deregistered/N5568J-2018-05-30), registration cancelled 2018-05-30, S/N 32-1032, built 1968 (OpenAirDocs) - Reported make and model: PIPER PA-32 (260) - Registry model: [Piper PA-32-260](https://openairdocs.org/model/piper-pa-32-260) (registry code 7103206) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 32-1032 - Year built: 1968 - Airframe hours: 6019 - Engines: LYCOMING O-540 SERIES 250 horsepower reciprocating - Damage: Substantial damage - Fire: In-Flight - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 17, 2015, 7 hours before - Departed: KOPF, Opa Locka, FL - Destination: MYBS, South Bimini, AOBF - Flight plan: VFR - Airport: KOPF, Opa Locka, runway 12, 6,800 × 150 ft, asphalt - Equipment: Auto-pilot, Handheld GPS, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 72; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review November 28, 2015; seat: left; restraint: lap only; flight hours: 1,786 total, 1,710 in this make and model, 5 in the last 90 days, 3 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 70° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: 2,700 ft broken - Temperature: 79 °F, dew point 73 °F - Altimeter: 30.04 inHg - Observed at: OPF, 1 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 20151201021339A](https://openairdocs.org/incident/20151201021339A), Dec 1, 2015: Piper PA-32-260, Opa_locka, FL, Destroyed. Pilot departed opa Locka airport (kopf) and around 800 feet of altitude he smell something coming from the vents between the glareshield and windshield, at… ## Docket (8 files) The files NTSB released with the investigation on March 30, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92382. 9.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450559&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot Statement (item 2, .PDF, 202 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450560&FileExtension=.PDF&FileName=Pilot%20Statement-Master.PDF - Previous Three Annual Inspections (item 3, .PDF, 648 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450561&FileExtension=.PDF&FileName=Previous%20Three%20Annual%20Inspections-Master.PDF - Selected Engine Inspections (item 4, .PDF, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450562&FileExtension=.PDF&FileName=Selected%20Engine%20Inspections-Master.PDF - Excerpt, Piper Cherokee Service Manual (item 5, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450563&FileExtension=.PDF&FileName=Excerpt,%20Piper%20Cherokee%20Service%20Manual-Master.PDF - Advisory Circular 91-59A (item 6, .PDF, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450564&FileExtension=.PDF&FileName=Advisory%20Circular%2091-59A-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 7, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450565&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Examination Photo Array (item 8, .PDF, 9 photos, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450566&FileExtension=.PDF&FileName=Examination%20Photo%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.