ERA17LA275

NTSB accident investigation · Piper J3C · Salisbury, CT · August 13, 2017

Accident · Minor injuriesLimited investigationFinal report
Date
August 13, 2017, 17:00 local (21:00 UTC)
Place
Salisbury, CT
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N98550Piper J3C
Defining event
Enroute-cruise: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report April 8, 2019
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Continental Motors
FAA report
20170813013369A
Case key
95807

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

An improper replacement of the crankshaft by maintenance personnel, which resulted in a failure of the crankshaft gear and total loss of engine power.

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.

Maintenance: replacementPersonnel issues › Task performance · Maintenance personnelPiper J3C-65: 1 caseAll aircraft: 70 casesProbable cause
Object/animal/substance: tree(s)Environmental issues › Physical environment · Contributed to outcomePiper J3C-65: 11 casesAll aircraft: 933 cases

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

During cruise flight, the airplane experienced a total loss of engine power, and the flight instructor performed a forced landing into trees. The engine crankshaft was replaced about 4 years and about 317 hours of operation before the accident. Teardown examination of the engine revealed that the crankshaft gear screws were fractured, and the crankshaft gear was separated from the crankshaft. Fretting was observed near two of the four crankshaft screw holes and corresponded to two elongated screw holes on the crankshaft gear. The crankshaft and crankshaft gear did not contain a dowel pin as specified in the most current versions of the manufacturer's illustrated parts catalog and overhaul manual, which were published more than 2 years before the crankshaft replacement. Additionally, the crankshaft gear did not contain a dowel pin hole, which was consistent with a crankshaft gear for an older, different model engine. Both publications contained numerous instructions and references to use a crankshaft gear with a dowel pin hole and to align the gear to the crankshaft with a dowel pin, which would pilot the crankshaft gear on the crankshaft. Thus, it is likely that when the crankshaft was replaced, maintenance personnel did not use the most recent manuals and installed a crankshaft gear for a different engine, which led to the crankshaft gear's failure and the subsequent loss of all engine power.

Factual narrative

On August 13, 2017, about 1700 eastern daylight time, a Piper J3C-65, N98550, operated by Berkshire Aviation Enterprises Inc., was substantially damaged during a forced landing into trees, following a total loss of engine power in cruise flight near Salisbury, Connecticut. The flight instructor and student pilot sustained minor injuries. The local instructional flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and a visual flight rules flight plan was filed for the flight that departed Walter J Koladza Airport (GBR), Great Barrington, Massachusetts, about 1640. The flight instructor reported that he was providing an introductory flight to the student pilot in that particular make and model airplane. About 20 miles south of GBR at 2,800 feet mean sea level, the airplane experienced a total loss of engine power. The flight instructor took control of the airplane from the student pilot and positioned the carburetor heat to on. He also verified that the fuel selector was in the on position and the magneto switch was set to both, but the engine did not regain power. There were no suitable landing areas nearby and the flight instructor elected to perform a slow landing into treetops. The airplane subsequently collided with trees and came to rest nose-down entangled in the trees. The airplane was equipped with a Continental Motors C90-8F, 90-horspower engine. The airplane's most recent annual inspection was performed on July 13, 2017. At that time, the airframe had accumulated 2,093 hours of operation. Review of the engine logbook revealed that maintenance records prior to 1994 were lost and a new engine logbook was created in June 1994, indicating that the engine was overhauled at a total estimated time of 1,300 hours. In October 2013, at 689 hours since major overhaul, the engine was disassembled and inspected after being involved in a previous accident (NTSB ID # ERA11LA379). During that work, the crankshaft was replaced per "Continental Overhaul Manual dated 1-1994." The engine had accrued about 317 hours from the time of the most recent crankshaft replacement, to the most recent annual inspection. Examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the wings and fuselage. When the inspector rotated the crankshaft by hand, he was unable to confirm thumb compression to two cylinders or continuity to the rear accessory section. A teardown examination of the engine was subsequently completed at the manufacturer's facility, under the supervision of an NTSB investigator. The examination revealed that the crankshaft gear screws were fractured, and the crankshaft gear was separated from the crankshaft. Fretting was observed near two of the four crankshaft screw holes and corresponded to two elongated screw holes on the crankshaft gear. The crankshaft gear contained an oil stain witness mark in an area that coincidedwith a dowel pin hole on the crankshaft; however, the crankshaft and crankshaft gear did not contain a dowel pin as specified in the most current version of the manufacturer illustrated parts catalog (IPC) and overhaul manual (OM). Additionally, the crankshaft gear did not contain a dowel pin hole, which was consistent with a crankshaft gear for a C65 engine and not a C90 engine. The manufacturer's most recent IPC and OM were published in August 2011, which was more than 2 years prior to the most recent crankshaft replacement in 2013. Both publications contained numerous instructions and references to use a crankshaft gear with a dowel pin hole and align the gear to the crankshaft with a dowel pin, which would pilot the crankshaft gear on the crankshaft.

Aircraft

Registration
N98550
Reported as
Piper J3C (65)
Category
Airplane
Serial number
18763
Built
1946
Airframe hours
2,093
Engine
Continental Motors C90-8F, 90 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Berkshire Aviation Enterprises Inc
Registered owner
Jacobs Jim J
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 13, 2017
Departed
GBR · Great Barringto, MA
Destination
GBR · Great Barringto, MA
Flight plan
VFR
Equipment
None

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
46
Injuries
Minor
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
December 22, 2016
Seat
Front
Restraint
Lap only
Flight hours
1,216 total · 263 in this make and model · 1,097 as pilot in command · 115 in the last 90 days · 42 in the last 30 days · 6 in the last 24 hours
Role
Student pilot
Age
59
Injuries
Minor
Certificate
Student
Medical
Class 3, With waivers/limitations
Seat
Rear
Restraint
3-point
Flight hours
100 total · 0 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 9 knots, gusting 14
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 57 °F
Altimeter
29.93 inHg
Observed at
BDL, 25 nm away

Docket · 7

The files NTSB released with the investigation on December 10, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.0 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.

Other investigations on N98550 · 1

Matched to the same aircraft by N-number and date.