# NTSB ERA16LA071: Piper PA-32, N8675N, Brunswick, GA, December 15, 2015 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: December 15, 2015, 10:50 local (15:50 UTC) - Place: Brunswick, GA - Coordinates: 31.158889, -81.489166 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=31.1589&lon=-81.4892&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report August 16, 2016 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 92462 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16LA071 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92462/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92462 - Page: https://openairdocs.org/ntsb/ERA16LA071 ## 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 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-32-300, 6 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=7103212), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Maintenance](https://openairdocs.org/ntsb-findings/02062000): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-32-300, 3 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md?model=7103212), [All aircraft, 143 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md) - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-32-300, 6 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=7103212), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-32-300, 25 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7103212), [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-32-300, 23 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7103212), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-32-300, 43 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103212), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N8675N-2018-06-08), registration cancelled 2018-06-08, S/N 32-7240019, built 1971 (OpenAirDocs) - Reported make and model: PIPER PA-32 (300) - Registry model: [Piper PA-32-300](https://openairdocs.org/model/piper-pa-32-300) (registry code 7103212) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 32-7240019 - Year built: 1971 - Airframe hours: 5032.6 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; injuries: minor; 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 files) The files NTSB released with the investigation on May 31, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92462. 2.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 636 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440579&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot Statement (item 2, .PDF, 188 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440580&FileExtension=.PDF&FileName=Pilot%20Statement-Master.PDF - Copies of Engine Logbook (item 3, .PDF, 401 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440581&FileExtension=.PDF&FileName=Copies%20of%20Engine%20Logbook-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 4, .PDF, 148 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440582&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Photos (item 5, .PDF, 3 photos, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440583&FileExtension=.PDF&FileName=Photos-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.