ERA16LA071

NTSB accident investigation · Piper PA-32 · Brunswick, GA · December 15, 2015

Accident · Minor injuriesLimited investigationFinal report
Date
December 15, 2015, 10:50 local (15:50 UTC)
Place
Brunswick, GA
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N8675NPiper PA-32
Defining event
Enroute: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report August 16, 2016
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
Case key
92462

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

Maintenance personnel's failure to properly torque a No. 4 cylinder hold-down nut during engine overhaul, which resulted in the loosening of the nut and the subsequent failure of the studs and through bolts and separation of the cylinder.

Findings · 3

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.

MaintenancePersonnel issues › Task performance · Maintenance personnelPiper PA-32-300: 3 casesAll aircraft: 143 casesProbable cause
Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · Incorrect service/maintenancePiper PA-32-300: 6 casesAll aircraft: 373 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 was conducting a personal cross-country flight. The pilot reported that the airplane was in cruise flight at 7,500 ft mean sea level when, without any warning, there was a loud explosion from the engine and an immediate loss of engine power. The explosion caused the oil filler door to open, and oil subsequently spewed over the windshield, and smoke filled the cockpit. The pilot declared an emergency and attempted to glide to a nearby airport; however, he landed the airplane on a rooftop a few hundred yards short of the runway. Examination of the engine revealed that the No. 4 cylinder had separated from the engine case. All of the No.4 cylinder mounting stubs and through bolts were fractured except for the bottom forward stub; the nut for this stub was not located. The piston and corresponding connecting rod for the No. 4 cylinder were found in the bottom of the engine cowling. A review of the engine maintenance logbooks revealed that the engine was overhauled almost 8 years before the accident and had accrued a total time of 1,005.0 hours since overhaul. There were no subsequent maintenance entries related to the No. 4 cylinder. Based on the evidence, it is likely that maintenance personnel applied insufficient torque to the cylinder's bottom forward hold-down nut, which allowed it to loosen over time. The stress load was then transferred to the remaining nuts, which resulted in the failure of the stubs and through bolts and to the separation of the No. 4 cylinder.

Factual narrative

On December 15, 2015, at 1050 eastern standard time, a Piper PA-32-300, N8675N, made a forced landing about .1-mile north of Malcolm McKinnon Airport (SSI), Brunswick, Georgia, after a catastrophic engine failure. The pilot and the passenger sustained minor injuries. The airplane landed on the roof of a home and collided with trees which resulted in substantial damage to the fuselage and wings. The airplane was registered to a private company and operated as a 14 Code of Federal Regulations (CFR) Part 91 personal flight. Visual flight rules conditions existed near the accident site at the time of the accident. No flight plan was filed for the flight that originated from Jacksonville Executive at Craig Airport (CRG), Jacksonville, Florida, about 1020 and was destined for the Rock Hill/York County/Bryant Field (UZA), Rock Hill, South Carolina. The pilot stated that he was in cruise flight at 7,500 ft mean sea level (msl) when, without any warning, there was a loud explosion from the engine and an immediate loss of engine power. The explosion caused the oil filler door to open and it partially pushed the Garmin 430 out of the dashboard. Oil spewed all over the windshield and smoke filled the cockpit. The pilot declared an emergency and attempted to glide to St. Simons Airport, St. Simons, Georgia; however, he landed on a rooftop a few hundred yards short of the runway. There was no post-impact fire. An examination of the engine was conducted on January 26, 2016, by the National Transportation Safety Board (NTSB). The examination revealed the No. 4 cylinder had separated from the engine case. The cylinder skirt was split in several areas consistent with the piston making contact with the cylinder after it separated from the case. Groove marks etched on the top of the piston were consistent with it striking the cylinder skirt. All of the No.4 cylinders mounting stubs and thru-bolts were fractured except for the bottom forward stud. The piston and corresponding connecting rod for the No. 4 cylinder were found in the bottom of the engine cowling. The other engine components appeared unremarkable. The engine was completely disassembled and the No. 4 crank-journal showed no signs of bearing migration or excessive heat. However, there were numerous gouges and scratches throughout the inside of the engine from debris after the cylinder separated. A review of the engine logbook revealed the engine was overhauled in February 2007 and installed on the airplane on March 16, 2007. The last engine inspection was completed on November 17, 2015, at total time of 1,005.0 hours since overhaul. A review of the engine's maintenance history since it was overhauled revealed no maintenance had been done to the No. 4 cylinder.

Aircraft

Registration
N8675N
Reported as
Piper PA-32 (300)
Category
Airplane
Serial number
32-7240019
Built
1971
Airframe hours
5,032.6
Engine
Lycoming IO-550, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Kdk Associates Inc
Registered owner
Kdk Associates Inc
Airworthiness certificate
Standard, Normal
Last inspection
Condition · November 17, 2015
Departed
CRG · Jacksonville, FL
Destination
UZA · Rock Hill, SC
Airport
SSI · Malcolm McKinnon
Equipment
Onboard weather, Auto-pilot, Electronic multifunction display

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
44
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
March 16, 2015
Seat
Left
Restraint
3-point
Flight hours
143 total · 65 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 4 knots
Visibility
10 statute miles
Temperature
70 °F, dew point 54 °F
Altimeter
29.94 inHg
Observed at
SSI, 1 nm away

Docket · 5

The files NTSB released with the investigation on May 31, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.4 MB in all.