# NTSB ERA18LA265: Piper PA32, N4592X, Bartow, FL, September 28, 2018 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: September 28, 2018, 13:25 local (17:25 UTC) - Place: Bartow, FL - Coordinates: 27.937221, -81.855552 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=27.9372&lon=-81.8556&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report November 19, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 98373 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18LA265 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98373/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98373 - Page: https://openairdocs.org/ntsb/ERA18LA265 ## Probable cause A total loss of engine power after the separation of the No. 3 cylinder from the crankcase due to improper maintenance. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance](https://openairdocs.org/ntsb-findings/02062000): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-32-300, 3 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md?model=7103212), [All aircraft, 143 cases](https://openairdocs.org/ntsb-findings/02062000/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-32-300, 6 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=7103212), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Piper PA-32-300, 3 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=7103212), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Piper PA-32-300, 25 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7103212), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-32-300, 23 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7103212), [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-32-300, 43 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103212), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N4592X-2023-10-07), registration cancelled 2023-10-07, S/N 32-7640039, built 1975 (OpenAirDocs) - Reported make and model: Piper PA32 (300) - Registry model: [Piper PA-32-300](https://openairdocs.org/model/piper-pa-32-300) (registry code 7103212) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 32-7640039 - Year built: 1975 - Airframe hours: 4047 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 70; injuries: minor; 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 ## 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 20180928016469A](https://openairdocs.org/incident/20180928016469A), Sep 28, 2018: Piper PA-32-300, Bartow, FL, Destroyed. Pilot & passenger departed boca raton airport with no problem. About 10 miles south of lakeland, FL, the aircraft engine began to run roughly, the pilot… ## Docket (5 files) The files NTSB released with the investigation on December 10, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98373. 3.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469110&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Interview Summary (item 2, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469111&FileExtension=.PDF&FileName=Interview%20Summary-Master.PDF - Excerpts from Maintenance Records (item 3, .PDF, 182 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469112&FileExtension=.PDF&FileName=Excerpts%20from%20Maintenance%20Records-Master.PDF - Memorandum for Record - Engine Exam (item 4, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469113&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Engine%20Exam-Master.PDF - Photo Array (item 5, .PDF, 3 photos, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469114&FileExtension=.PDF&FileName=Photo%20Array-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.