# NTSB ERA17LA110: Piper PA28R, N15745, Bayonne, NJ, February 19, 2017 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: February 19, 2017, 10:00 local (15:00 UTC) - Place: Bayonne, NJ - Coordinates: 40.668609, -74.114166 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.6686&lon=-74.1142&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report April 9, 2018 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, The New Piper Aircraft Company, Lycoming - NTSB case key (mKey): 94725 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17LA110 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94725/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94725 - Page: https://openairdocs.org/ntsb/ERA17LA110 ## Probable cause Maintenance personnel’s incorrect installation of the No. 3 cylinder’s hydraulic valve tappet plunger, which resulted in a failure of the No. 3 cylinder’s intake valve and the subsequent partial loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-28R-200, 7 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=7102811), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-28R-200, 4 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=7102811), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28R-200, 4 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=7102811), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/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-28R-200, 4 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=7102811), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Object/animal/substance: wire](https://openairdocs.org/ntsb-findings/03022032): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28R-200, 1 case](https://openairdocs.org/ntsb-findings/03022032/cases.md?model=7102811), [All aircraft, 588 cases](https://openairdocs.org/ntsb-findings/03022032/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Piper PA-28R-200, 7 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=7102811), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Maneuvering: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Piper PA-28R-200, 9 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7102811), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Maneuvering: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Piper PA-28R-200, 4 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=7102811), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28R-200, 30 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102811), [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-28R-200, 45 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102811), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The private pilot reported that the personal local flight was uneventful until the engine made an odd noise, which was followed by a partial loss of engine power. The pilot attempted to troubleshoot the problem, but the engine power was not fully restored, and the airplane was unable to maintain altitude, so the pilot made a forced landing to a road. The airplane struck power lines and vehicles before coming to rest on a sidewalk. Postaccident examination of the engine revealed that the No. 3 cylinder's intake valve had separated. The valve stem was found in the oil pan, and the remainder of the valve was found in its intake manifold. Metallurgical examination of the No. 3 cylinder assembly, including the fractured intake valve, revealed that the valve was fractured in the stem in two places and through the head in one place. The interior of the cylinder exhibited damage consistent with impacts from the fractured valve. The connecting rod was intact, but the bearings were worn through both the babbit and copper layers. Examination of the fracture surfaces revealed fatigue cracks initiating from the fillet radius between the valve stem tip and the key area of the stem shaft. The other fractures were consistent with overstress. Further examination of the engine case revealed that all eight hydraulic valve tappet plungers were installed 180° opposite of the proper installation contained in the manufacturer's overhaul manual. The reversed installation of the plunger would have adversely affected the operation of the No. 3 cylinder's intake valve and placed an abnormal load on the valve's tip. A review of the engine's maintenance logbook revealed that the engine had been repaired about 35.7 hours before the accident. At that time, all four cylinders were removed and replaced, including the hydraulic valve tappet plunger assemblies. Given that the cylinders had been recently removed and reinstalled on the engine, including the hydraulic valve tappet plungers, it is likely that the engine experienced a partial loss of engine power due to maintenance personnel's improper installation of the No. 3 cylinder's hydraulic valve tappet plunger. ## Factual narrative On February 19, 2017, about 1000 eastern standard time, a Piper PA-28R-200, N15745, sustained substantial damage during a forced landing to a road in Bayonne, New Jersey. The private pilot was seriously injured. The airplane was registered to and operated by a private company. Visual meteorological conditions prevailed and no flight plan was field for the local flight that departed Republic Airport (FRG), Farmingdale, New York, about 0900. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. The pilot stated that he had not flown since August 2016 and was taking the club-rented airplane, that he had previously trained in and flown, out for a pleasure flight. He conducted a pre-flight inspection and confirmed that both fuel tanks were "topped off" and added 1 quart of oil for a total of 7 quarts. The pilot then taxied to the active runway, performed an engine run-up, and departed. The pilot said the flight was uneventful until he approached the Statue of Liberty and Verrazano Bridge. That is when, and without any warning, he heard a "foomph" noise come from the engine along with a "white mist" that appeared for less than 1 second and never returned. At this point, the pilot realized that the engine had lost power (he could not estimate how much) and he was having trouble maintaining altitude. He said he attempted to trouble shoot the problem. Although he did not recall the exact sequence of things, the pilot said he switched fuel tanks from left to right, checked the ignition, and looked quickly at the engine gauges. The pilot recalled that the manifold pressure was "all the way up", but he did not remember what the other gauges indicated. He had also moved the propeller lever full forward and declared a "May Day" over the radio. He said the engine never lost full power. The pilot declared an emergency, flew toward land, and made a forced landing to a road. The airplane struck power lines and vehicles before coming to rest on a sidewalk in a congested city neighborhood. There was no post-impact fire or injuries to anyone on the ground. The airplane sustained substantial damage to the wings, tail section and fuselage. The engine was separated from the airframe for examination. The valve covers were removed and oil was noted throughout the engine. About .5-ounce of fuel was recovered from the fuel servo and .25- ounce was recovered from the engine driven fuel pump. The fuel was blue, clear, and consistent with 100-low-lead aviation gasoline. When the engine driven fuel pump was actuated by hand, suction and compression were confirmed at the inlet and outlet port. The oil suction screen was removed and some metallic contamination was observed in the screen. The oil filter was opened and also contained metallic contamination. A timing check of the magnetos revealed that they were near their specification of 20° prior to top dead center. Both magnetos produced spark at all leads when rotated by hand. Thetop spark plugs were removed and their electrodes were intact. When the propeller was rotated by hand, camshaft, crankshaft, and valve train continuity were confirmed to the rear accessory section. Thumb compression was attained on the No. 1 and No. 4 cylinders. The No. 2 cylinder was impact damaged and the No. 3 cylinder exhibited a small hole near the intake manifold of the cylinder. Removal of the No. 3 cylinder revealed that the intake valve had separated and the valve stem was recovered in the oil pan. The remainder of the No. 3 valve was recovered from its intake manifold. Further examination of the engine case revealed that all eight hydraulic valve tappet plungers were installed 180°opposite from proper installation per the manufacturer's overhaul manual. The No. 3 cylinder assembly, including the fractured intake valve, was examined at the National Transportation Safety Board Materials Laboratory, Washington, DC. The examination revealed the intake valve was fractured in the stem in two places and through the head in one place. The interior of the cylinder exhibited damage consistent with the impacts from the fractured valve. The connecting rod was intact, but the bearings were worn through both the babbit and copper layers. Examination of the fracture surfaces revealed fatigue cracks initiating from the fillet radius between the valve stem tip and the key area of the stem shaft. The other fractures were consistent with overstress. A review of the aircraft maintenance logbooks revealed the engine was repaired about 35.7 hours prior to the accident on January 9, 2017. At that time, all four cylinders were removed and reinstalled, including the hydraulic valve tappet assemblies for each cylinder. According to the entry, the mechanic wrote, "All work performed I/A/W Lycoming overhaul and service manuals as well as Piper service manual. Aircraft approved for return to service." The Lycoming Direct Drive Engine Overhaul Manual, pages 6-7 and 6-8, discusses the hydraulic valve tappet assemblies along with an illustration (figure 6-9) that depicts how the tappet plungers are to be oriented once installed in the engine. Weather at Newark International Airport (EWR), Newark, New Jersey, about 6 nautical miles northwest of the accident site, at 0951, was reported as wind from 250° at 8 knots, visibility 10 statute miles, scattered clouds at 12,000 ft, broken clouds at 27,000 ft, temperature 61° F, dew point 37° F, and an altimeter setting of 29.82 inHg. ## Aircraft - Registration: [N15745](https://openairdocs.org/deregistered/N15745-2019-08-13), registration cancelled 2019-08-13, S/N 28R-7335087, built 1972 (OpenAirDocs) - Reported make and model: PIPER PA28R (200) - Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7335087 - Year built: 1972 - Airframe hours: 7059.07 - Engines: LYCOMING IO-360 210 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, October 17, 2016, 69 hours before - Departed: FRG, FARMINGDALE, NY - Destination: FRG, FARMINGDALE, NY - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review March 7, 2016; seat: left; flight hours: 97.5 total ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: 27,000 ft broken - Temperature: 61 °F, dew point 37 °F - Altimeter: 29.81 inHg - Observed at: EWR, 6 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 20170219007759A](https://openairdocs.org/incident/20170219007759A), Feb 19, 2017: Piper PA-28R-200, Bayonne, NJ, Destroyed. The subject aircraft departed kfrg February 19, 2017 approximately 0900 eastern standard time. During the flight while near the statue of liberty the aircraft… ## Docket (9 files) The files NTSB released with the investigation on February 20, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94725. 7.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460211&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation - Pilot (item 2, .PDF, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460212&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot-Master.PDF - Pages from Lycoming Overhaul Manual (item 3, .PDF, 478 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460227&FileExtension=.PDF&FileName=Pages%20from%20Lycoming%20Overhaul%20Manual-Master.PDF - Maintenance Records (item 4, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460213&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF - Memorandum of Record - Engine Exam (item 5, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460214&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20-%20Engine%20Exam-Master.PDF - Photos (item 6, .PDF, 7 photos, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460215&FileExtension=.PDF&FileName=Photos-Master.PDF - Materials Laboratory Factual Report 17-042 (item 7, .PDF, 5 photos, 693 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460216&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report%2017-042-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 487 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460217&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 and Evidence Control Form (item 9, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460218&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15%20and%20Evidence%20Control%20Form-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.