ERA18LA265

NTSB accident investigation · Piper PA32 · Bartow, FL · September 28, 2018

Accident · Minor injuriesLimited investigationFinal report
Date
September 28, 2018, 13:25 local (17:25 UTC)
Place
Bartow, FL
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4592XPiper PA32
Defining event
Enroute-cruise: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report November 19, 2019
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20180928016469A
Case key
98373

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

A total loss of engine power after the separation of the No. 3 cylinder from the crankcase due to improper maintenance.

Findings · 2

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.

MaintenancePersonnel issues › Task performance · Maintenance personnelPiper PA-32-300: 3 casesAll aircraft: 143 casesProbable cause
Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · Incorrect service/maintenancePiper PA-32-300: 6 casesAll aircraft: 373 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 private pilot reported that during cruise flight, the engine began to run roughly. The No. 3 cylinder then separated from the airplane; the engine lost all power, and oil began to cover the windshield. The pilot flew via instruments and landed in a marsh; the right wing of the airplane separated after contacting a tree. Postaccident engine examination revealed impact marks on the engine crankcase where the No. 3 cylinder would have been secured. The marks were consistent with the cylinder impacting the case multiple times. The examination also revealed that several of the nuts on other cylinders were well below the required 50 ft-lbs of torque. The engine's most recent overhaul was completed about 12 years before the accident, and the engine had accrued about 366 hours since that overhaul; there was no record of cylinder removal or replacement since the engine overhaul. It is likely that undertorqued cylinder nuts allowed the cylinder to come loose and separate from the engine. The investigation could not determine if the undertorqued condition of the cylinder nuts was the result of an improper overhaul or possible improper undocumented maintenance after the overhaul.

Factual narrative

On September 28, 2018, about 1325 eastern daylight time, a Piper PA-32-300, N4592X, operated by the private pilot, was substantially damaged during a forced landing to a marsh, following a total loss of engine power during cruise flight near Bartow, Florida. The private pilot and passenger sustained minor injuries. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for planned flight to Tampa Executive Airport (VDF), Tampa, Florida. The flight originated from Boca Raton Airport (BCT), Boca Raton, Florida, about 1230.The pilot reported that during cruise flight, the engine began to run rough. He notified air traffic control (ATC) and declared an emergency. Shortly thereafter, the engine cowling separated and the pilot observed that a cylinder had separated as oil began to cover the windscreen. Although ATC provided vectors to the nearest airport, the pilot could not see due to the oil, and flew via the instruments to the ground. Examination of the accident site by a Federal Aviation Administration inspector revealed that during the landing in a marsh, the right wing contacted a tree and separated. The inspector also observed that the No. 3 cylinder had separated. Further examination of the engine following recovery revealed impact marks on the engine crankcase where the No. 3 cylinder secured to it. The marks were consistent with the cylinder impacting the case multiple times. The examination also revealed that several of the other cylinder nuts were below the required 50 ft/lbs of torque. The six-seat, low-wing, fixed-tricycle-gear airplane was manufactured in 1975. It was powered by a Lycoming IO-540, 300-horsepower engine, equipped with a constant-speed, two-blade Hartzell propeller. Review of maintenance records revealed that the engine's most recent overhaul was completed on November 14, 2006. The airplane's most recent annual inspection was completed on March 16, 2018. At the time, the engine had accrued 353.58 hours since the overhaul. There was no record of any cylinder removal or replacement since the engine overhaul. The airplane had flown about 13 additional hours from the time of the most recent annual inspection, until the accident.

Aircraft

Registration
N4592X
Reported as
Piper PA32 (300)
Category
Airplane
Serial number
32-7640039
Built
1975
Airframe hours
4,047
Engine
Lycoming IO-540-K1A5, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 16, 2018 · 13 hours before
Departed
BCT · Boca Raton, FL
Destination
VDF · Tampa, FL
Flight plan
IFR
Equipment
Stall warning system, ADS-B, Auto-pilot, Electronic flight bag or handheld device, Onboard weather

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
70
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
BasicMed
Last flight review
September 28, 2017
Seat
Left
Restraint
3-point
Flight hours
465 total · 382 in this make and model · 465 as pilot in command · 7 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
110° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 72 °F
Altimeter
30.06 inHg
Observed at
BOW, 5 nm away

Docket · 5

The files NTSB released with the investigation on December 10, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.3 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.