- 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.
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.