# NTSB ERA17LA128: Piper PA28, N8447R, Tampa, FL, March 12, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: March 12, 2017, 13:35 local (17:35 UTC) - Place: Tampa, FL - Coordinates: 27.910554, -82.449722 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=27.9106&lon=-82.4497&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report February 11, 2020 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - SAIBs cited in the narratives: [SAIB CE-14-23](https://openairdocs.org/saib/CE-14-23) (OpenAirDocs) - NTSB case key (mKey): 94855 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17LA128 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94855/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94855 - Page: https://openairdocs.org/ntsb/ERA17LA128 ## Probable cause A collapsed engine induction duct, which resulted in restricted air flow to the engine and a subsequent loss of engine power. Contributing to the accident was the operator's failure to ensure that the correct induction duct was installed. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance/inspections: scheduled maint checks](https://openairdocs.org/ntsb-findings/01010520): Aircraft › Aircraft handling/service · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-28-140, 4 cases](https://openairdocs.org/ntsb-findings/01010520/cases.md?model=7102802), [All aircraft, 76 cases](https://openairdocs.org/ntsb-findings/01010520/cases.md) - [Power plant: air intake](https://openairdocs.org/ntsb-findings/01057160): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-28-140, 3 cases](https://openairdocs.org/ntsb-findings/01057160/cases.md?model=7102802), [All aircraft, 50 cases](https://openairdocs.org/ntsb-findings/01057160/cases.md) - [Terrain: water](https://openairdocs.org/ntsb-findings/03021020): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-140, 2 cases](https://openairdocs.org/ntsb-findings/03021020/cases.md?model=7102802), [All aircraft, 97 cases](https://openairdocs.org/ntsb-findings/03021020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Piper PA-28-140, 47 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7102802), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-140, 56 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102802), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Emergency descent: Ditching](https://openairdocs.org/ntsb-events/441); cases with it: [Piper PA-28-140, 2 cases](https://openairdocs.org/ntsb-events/441/sequence.md?model=7102802), [All aircraft, 186 cases](https://openairdocs.org/ntsb-events/441/sequence.md) ## Analysis The private pilot stated that he rented the airplane 2 days before the accident flight to fly across the state for several days. On the day of the accident, the pilot performed a preflight inspection of the airplane with no anomalies noted. After takeoff and during the initial climb, the pilot noticed a loss of engine power, and the rpm started to drop. He attempted to return to the departure airport and land on an intersecting runway, but during the turn, he realized he would not make it back to the airport; he ditched the airplane into the surrounding water. The airplane was substantially damaged during the ditching. Postaccident examination of the airplane revealed that the induction duct from the air filter to the carburetor had collapsed, which likely restricted air flow to the engine and ultimately resulted in the loss of engine power. Further examination revealed that the induction duct on the accident airplane was not approved for installation on the engine. About 3 years before the accident, the Federal Aviation Administration had issued a special airworthiness information bulletin recommending operators inspect airplanes of this model to ensure that the correct induction duct was installed; that there was no loose or displaced supporting wire or signs of wear, perforation, or deterioration; and that the part had not collapsed. However, the operator was unaware of the bulletin and had not performed the inspection. After the accident, the operator inspected the fleet and installed the approved part on all affected airplanes. ## Factual narrative On March 12, 2017, about 1335 eastern daylight time, a Piper PA-28-140, N8447R, impacted the water during a forced landing shortly after takeoff from Peter O Knight Airport (TPF), Tampa, Florida. The private pilot was not injured. Visual meteorological conditions prevailed and no flight plan was filed for the flight to Sabastian Municipal Airport (X26), Sabastian, Florida. The personal flight was conducted in accordance with the provisions of 14 Code of Federal Regulations Part 91.According to the pilot, he rented the airplane two days prior to the accident flight, to fly from X26 to TPF for several days. The flight on March 10 was uneventful. On March 12, he arrived at the airport around 1230 and started his preflight inspection of the airplane. The pilot stated he "sumped" the tanks and the fuel was clear of debris. The rest of the preflight inspection was normal and no anomalies were noted. The engine run-up and magneto checks were normal, and he started his take-off roll on runway 22. At 60 knots airspeed, he rotated and started to climb. Upon reaching about 100 ft above ground level, he noticed a loss of engine power and the rpm started to drop. He verified fuel and oil pressure were good and started looking for a place to land. He further stated he could not abort the take-off and land safely on the runway, so he decided to try to turn back to the airport and land on the cross runway. During the turn, he realized he would not make it back to the airport and decided to ditch the airplane into the surrounding water. Once he ditched the airplane, he exited through the cockpit door and a local boater picked him up and took him to shore. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the left wing separated from the airplane. The windshield was fractured in several areas and the right wing leading edge was damaged. Further examination of the wreckage by an investigator with the National Transportation Safety Board revealed the induction hose from the air filter to the carburetor was collapsed and the spring inside the duct was positioned sideways. The duct was sent to the airframe manufacturer for a visual examination. The examination revealed that the duct was not approved for installation on the PA-28-140 aircraft. Specifically, duct was not of a type that was approved for negative pressure environments. Also, the duct was not of the correct length, and it was not a double walled duct. Based on available information, it could not be determined when the duct had been installed onto the airplane. The FAA issued a Special Airworthiness Information Bulletin (SAIB), CE-14-23, on August 6, 2014, which recommended that operators and owners of the PA-28 inspect the air inlet hose [duct] and verify that it was an approved part and did not exhibit any loose or broken cords on the external surface. The inspection should also confirm that there was no loose or displaced supporting wire, or signs of wear,perforation, deterioration, and that the part had not collapsed. If any of these conditions were observed, then the hose must be replaced before next flight. The operator reported that they were unaware of the SAIB, and following the accident, immediately grounded their fleet of airplanes and inspected them for the approved Piper duct. They found that all the airplanes had the unapproved duct installed and immediately ordered and installed the approved part. ## Aircraft - Registration: [N8447R](https://openairdocs.org/deregistered/N8447R-2019-01-03), registration cancelled 2019-01-03, S/N 28-22331, built 1966 (OpenAirDocs) - Reported make and model: PIPER PA28 (140) - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-22331 - Year built: 1966 - Airframe hours: 5400 - Engines: LYCOMING 0-320 SERIES 140 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 7, 2017 - Departed: TPF, Tampa, FL - Destination: X26, SEBASTIAN, FL - Airport: TPF, Peter O Knight, runway 22, 3,583 × 100 ft, concrete - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; injuries: none; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; seat: left; restraint: lap only; flight hours: 231 total, 75 in this make and model, 135 as pilot in command, 10 in the last 90 days, 6 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 100° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 63 °F - Altimeter: 30.05 inHg - Observed at: KTPF ## 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 20170312001249A](https://openairdocs.org/incident/20170312001249A), Mar 12, 2017: Piper PA-28-140, Tampa, FL, Substantial damage. After takeoff on runway 5 at tpf, at approximately 200 AGL, the pilot experienced a reduction of engine power. The pilot turned crosswind and attempted to… ## Docket (8 files) The files NTSB released with the investigation on October 9, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94855. 5.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476658&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Inspector's Statement (item 2, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476659&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Master.PDF - Memorandum for Record – Telephone Interview, Pilot (item 3, .PDF, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476660&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Telephone%20Interview,%20Pilot-Master.PDF - Memorandum for Record (item 4, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478931&FileExtension=.PDF&FileName=Memorandum%20for%20Record-Master.PDF - Airframe Manufacturer Duct Examination Summary (Email) (item 5, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476661&FileExtension=.PDF&FileName=Airframe%20Manufacturer%20Duct%20Examination%20Summary%20(Email)-Master.PDF - Photos of Accident Duct and Exemplar (Approved) Duct (item 6, .PDF, 5 photos, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476662&FileExtension=.PDF&FileName=Photos%20of%20Accident%20Duct%20and%20Exemplar%20(Approved)%20Duct-Master.PDF - SAIB CE-4-23 (item 7, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476663&FileExtension=.PDF&FileName=SAIB%20CE-4-23-Master.PDF - Investigative Photos (item 8, .PDF, 4 photos, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476664&FileExtension=.PDF&FileName=Investigative%20Photos-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.