ERA16LA164

NTSB accident investigation · Piper PA28 · Okeechobee, FL · April 18, 2016

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
April 18, 2016, 15:30 local (19:30 UTC)
Place
Okeechobee, FL
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N151DCPiper PA28
Defining event
Enroute: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA FSDO, Piper
FAA report
20160418004109A
Case key
93030

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

The failure of the No. 3 piston due to fatigue cracking, which resulted in a total loss of engine power and subsequent forced landing, during which the airplane impacted obstacles.

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.

Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Attain/maintain not possiblePiper PA-28-161: 7 casesAll aircraft: 1,310 casesProbable cause
Object/animal/substance: ground vehicleEnvironmental issues › Physical environment · Contributed to outcomePiper PA-28-161: 3 casesAll aircraft: 132 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 operator reported that the pilot was conducting a cross-country, solo instructional flight. When the airplane was about 3,000 ft mean sea level, the engine suddenly started running roughly accompanied by “abnormal” noises. The pilot attempted to troubleshoot the problem by performing the “engine roughness” checklist to no avail. About 10 seconds after completing the checklist, the engine lost all power. The pilot then established the best glide speed, chose a private grass strip for a forced landing, and conducted the “engine power loss in flight” checklist without success. Once committed to landing, he conducted the “power off landing checklist.” After the airplane touched down about halfway down the grass strip it skidded and subsequently impacted farm equipment and other obstacles, and it then came to rest against a building. The airplane sustained substantial damage to the fuselage and tail section, and the wings were sheared off. Examination of the engine revealed that there was a hole in the crankcase above the No. 2 cylinder, consistent with a catastrophic engine failure, and that the No. 3 piston had failed. Metallurgical examination of the No. 3 piston revealed that two fatigue cracks had emanated from the outer face of a lubricating hole, which resulted in the piston failing, ancillary damage to the cylinder and engine, and a subsequent total loss of engine power. The areas outside of the fatigue crack regions and fracture faces exhibited a rough texture and on-slant planes consistent with overstress separation. The reason for the initiation and propagation of the fatigue cracks could not be determined. Even though the engine was 200 hours past the manufacturer’s recommended time before overhaul limit, it could not be determined if that contributed to the fatigue cracking.

Factual narrative

On April 18, 2016, about 1530 Eastern daylight time, a Piper PA-28-161, N151DC, was substantially damaged when it was involved in an accident near Okeechobee, Florida. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 solo instructional flight. The operator reported that, when the airplane was about 3,000 ft mean sea level, the engine suddenly started to run roughly accompanied by “abnormal” noises. The engine instruments remained in the normal range. The pilot attempted to troubleshoot the problem by performing the “engine roughness” checklist without success. Shortly after, the pilot contacted the Miami Air Route Traffic Control Center and reported the problem, and a controller suggested that the pilot proceed to the St Lucie County International Airport (FPR), Fort Pierce, Florida, where emergency services would be standing by. However, about 10 seconds after completing the checklist, the engine lost all power. The pilot then established the best glide speed and chose a private grass strip for forced landing and conducted the “engine power loss in flight” checklist without success. Once committed to landing, he conducted the “power off landing checklist.” After touching down, the airplane skidded and subsequently impacted farm equipment and other obstacles, and it then came to rest against a building. A review of the engine’s maintenance records revealed that it had accrued 10,382.8 total flight hours and 2,600.8 hours since the last overhaul. The engine manufacturer’s recommended time between overhaul was 2,400 hours. Postaccident examination of the airplane revealed that it had sustained substantial damage to the fuselage and tail section and that the wings had been sheared off. During postaccident examination of the engine, a hole was found in the crankcase above the No. 2 cylinder. Metal was found in most of the folds of the oil filter material and in the Nos. 3 and 4 cylinders, and ferrous and nonferrous materials were found throughout the crankcase. During a subsequent compression check, the No. 3 cylinder’s compression was excessively low, The No. 3 piston would not move when the crankshaft was manually rotated. After the No. 3 cylinder was removed, only the connecting rod and piston pin were found. The No. 3 cylinder’s interior was extensively damaged. Metallurgical examination of the No. 3 piston revealed that it was fractured and that it had two fatigue cracks emanating from the outer face of a lubricating hole in a groove for a compression ring. (See figure 1, which is a photograph showing the two fatigue cracks in the No. 3 piston in relation to the lubricating hose and compression ring groove. The white arrows indicate the general direction of the fatigue crack propagation.) The areas outside of the fatigue crack regions and fracture faces exhibited a rough texture and on-slant planes consistent with overstress separation. The reason for the initiation and propagationof the fatigue cracks could not be determined. Figure 1. Photograph showing the No. 3 piston’s two fatigue cracks in relation to the lubricating hole and compression ring groove and the general direction of the fatigue propagation.

Aircraft

Registration
N151DC
Reported as
Piper PA28 (161)
Category
Airplane
Serial number
2842138
Built
2001
Airframe hours
4,577
Engine
Lycoming 0-320 SERIES, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Flightsafety International Inc
Registered owner
Flightsafety International Inc
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
AAIP · April 15, 2016 · 3 hours before
Departed
APF · Naples, FL
Destination
VRB · Vero Beach, FL
Flight plan
VFR
Equipment
Stall warning system

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
23
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 1, Without waivers/limitations
Last flight review
March 21, 2016
Seat
Left
Restraint
3-point
Flight hours
84 total · 84 in this make and model · 26 as pilot in command · 43 in the last 90 days · 16 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
60° at 9 knots, gusting 18
Visibility
10 statute miles
Lowest ceiling
None
Temperature
77 °F, dew point 55 °F
Altimeter
30.15 inHg
Observed at
OBE, 16 nm away

Docket · 8

The files NTSB released with the investigation on February 23, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.7 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.