# NTSB ERA19LA272: Diamond DA40, N292RA, Norfolk, VA, September 15, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: September 15, 2019, 16:50 local (20:50 UTC) - Place: Norfolk, VA - Coordinates: 36.665554, -76.320556 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.6656&lon=-76.3206&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA FSDO - NTSB case key (mKey): 100280 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA272 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100280/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100280 - Page: https://openairdocs.org/ntsb/ERA19LA272 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) ## 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 (not matched to a registry record) - Reported make and model: DIAMOND DA40 - Category: Airplane - Serial number: 40.NC033 - Year built: 2018 - Airframe hours: 123 - Engines: 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. - Pilot; age 58; injuries: none; 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 ## 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 20190915013169A](https://openairdocs.org/incident/20190915013169A), Sep 15, 2019: Diamond Aircraft Ind Inc DA 40 NG, Chesapeake, VA, Substantial damage. While performing touch and go landings at cpk, aircraft climbed to 300 feet and experienced a complete power loss. Pilot executed an emergency landing… ## Docket (4 files) The files NTSB released with the investigation on May 22, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100280. 1.4 MB in all. - FAA Inspector's Statement (item 1, .PDF, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40483906&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Master.PDF - NTSB Summary of Conversation - FAA Inspector (item 2, .PDF, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40483907&FileExtension=.PDF&FileName=NTSB%20Summary%20of%20Conversation%20-%20FAA%20Inspector-Master.PDF - Photos (item 3, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40483908&FileExtension=.PDF&FileName=Photos-Master.PDF - Electronic Engine Control Unit - Plot (item 4, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40483910&FileExtension=.PDF&FileName=Electronic%20Engine%20Control%20Unit%20-%20Plot-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.