ERA19LA272

NTSB accident investigation · Diamond DA40 · Norfolk, VA · September 15, 2019

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
September 15, 2019, 16:50 local (20:50 UTC)
Place
Norfolk, VA
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N292RADiamond DA40
Defining event
Takeoff: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA FSDO
FAA report
20190915013169A
Case key
100280

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 partial loss of engine power due to the mechanic's failure to properly tighten the two clamps securing the flexible coupling from the intercooler to the induction inlet.

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.

Maintenance: installationPersonnel issues › Task performance · Maintenance personnelAll aircraft: 371 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · Incorrect service/maintenanceAll aircraft: 497 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 pilot said that, shortly after takeoff, he heard a noise from under the engine cowling followed by a partial loss of engine power. The pilot was unable to maintain altitude and made a forced landing to a field, which resulted in substantial damage to the fuselage. Data downloaded from the airplane's electronic engine control unit was consistent with an uncommanded decrease in induction air boost pressure on takeoff. Postaccident examination of the engine revealed that the flexible induction coupling between the intercooler and the engine induction inlet had backed off. The two clamps that secured the flexible coupling to the induction inlet were intact and safety wired. However, the two clamps were loose, and the induction tube could be inserted into the coupling without loosening the clamps. A review of maintenance records revealed that the flexible induction coupling and clamps had been removed and replaced at the last 100-hour inspection about 15 flight hours before the accident. Because the two clamps that secured the coupling from the intercooler to the induction inlet were recently replaced, it is likely that the mechanic who installed the clamps did not properly tighten them, and they loosened in flight, leading to the induction inlet backing off and resulting in a loss of engine power.

Factual narrative

On September 15, 2019, about 1650 eastern daylight time, a Diamond DA40, N292RA, sustained substantial damage during a forced landing to a field after a partial loss of engine power on takeoff from the Chesapeake Regional Airport (CPK), Norfolk, Virginia. The private pilot was not injured. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the local, personal flight. The pilot stated that he completed three touch-and-go landings without incident and the airplane performed "completely normally." After the last landing, the pilot again initiated another takeoff and began to climb. When the airplane reached an altitude of 300 ft above the ground, and with no available runway remaining, the pilot heard a noise from under the engine cowling followed by a "near complete loss of engine thrust." The pilot realized that he was unable to maintain altitude and made a forced landing to a soybean field. The landing was smooth until the nose wheel struck a drainage ditch and spun the airplane to the right about 90°. The pilot secured the airplane and exited. A postaccident examination of the airplane revealed the nose landing gear and lower engine cowling were damaged. The fuselage structure aft of the nose landing gear was substantially damaged and two of the three propeller blades had separated near the spinner. Data downloaded from the airplane's electronic engine control unit revealed there was an uncommanded decrease in induction air boost pressure on takeoff, which immediately prior to the loss of engine power. Examination of the engine revealed the flexible induction coupling from the intercooler to the engine induction inlet had backed off. The two clamps that secured the flexible coupling to the induction inlet were intact and safety wired. However, they were loose and the induction tube could be inserted into the coupling without any additional loosening of the clamps. A review of maintenance records revealed that the flexible induction coupling, and the clamps had been removed and replaced at the last 100-hr inspection on August 21, 2019, which was about 15 hours prior to the accident. At the time of the accident, the airplane had accrued a total of 123 hours. The pilot held a private pilot certificate with a rating for airplane single-engine land. His last Federal Aviation Administration (FAA) third-class medical certificate was issued on October 23, 2018. At that time, the pilot reported a total of 1,700 flight hours. Weather at CPK at 1635 was reported as wind from 080° at 3 knots, visibility 7 miles, light rain, and clear skies. The temperature was 29°C, the dewpoint was 20°C, with a barometric altimeter setting of 30.08 inches of mercury.

Aircraft

Registration
N292RA
Reported as
Diamond DA40
Category
Airplane
Serial number
40.NC033
Built
2018
Airframe hours
123
Engine
Austro Engines E4-A, 170 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 21, 2019 · 15 hours before
Departed
CPK · Norfolk, VA
Destination
CPK · Norfolk, VA
Airport
CPK · Chesapeake Rgnl, runway 05, 5,500 × 100 ft, asphalt
Equipment
Auto-pilot, Data recorder, Electronic flight bag or handheld device, Stall warning system, Onboard weather, Electronic primary flight display, Electronic multifunction display

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
58
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
March 27, 2019
Seat
Left
Restraint
3-point
Flight hours
1,881 total · 133 in this make and model · 1,840 as pilot in command · 66.1 in the last 90 days · 20.2 in the last 30 days · 4.5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
90° at 5 knots
Visibility
7 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 61 °F
Altimeter
30.12 inHg
Observed at
CPK, 5 nm away

Docket · 4

The files NTSB released with the investigation on May 22, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.4 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.