# NTSB ERA20LA011: Piper PA46, N4385K, Harrisburg, PA, October 4, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: October 4, 2019, 17:13 local (21:13 UTC) - Place: Harrisburg, PA - Coordinates: 40.176109, -76.726943 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.1761&lon=-76.7269&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR final approach: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Continental Motors - NTSB case key (mKey): 100432 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20LA011 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100432/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100432 - Page: https://openairdocs.org/ntsb/ERA20LA011 ## Probable cause A total loss of engine power for reasons that could not be determined following a successful engine run. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Piper PA-46-310P, 5 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=7104605), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR final approach: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-46-310P, 11 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7104605), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) ## Analysis The pilot reported that he was performing a visual approach for landing when the engine lost total power. Unable to restore engine power, the pilot performed a forced landing to a river. After recovery, the external engine components were dried, cleaned, and reinstalled (magnetos, fuel manifold), and the starter was replaced due to water immersion. The engine was then placed in a test cell where it started immediately, accelerated smoothly, and ran continuously without interruption. Radar and on-board data revealed that the airplane experienced lateral g-forces in the turn to final and during its approach in a gusting crosswind, consistent with a slip. Although the airplane’s operating handbook cautioned against prolonged slips or skids or other “radical or extreme maneuvers which could cause uncovering of the fuel outlet,” whether the slip during the accident flight was sufficient to uncover the fuel port and result in the loss of engine power could not be determined. ## Factual narrative On October 4, 2019, at 1713 eastern daylight time, a Piper PA46-310P, N4385K, was substantially damaged when it was involved in an accident near Harrisburg, Pennsylvania. The private pilot and a passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. In a written statement, the pilot stated that he conducted a thorough preflight inspection and had the airplane serviced with 30 gallons of 100LL aviation gasoline. He estimated that the 122-gallon fuel system contained 77 gallons of fuel at the time of departure. The pilot described the flight as "unremarkable." Upon arriving at the destination airport, he was cleared for a visual approach and stated that he referenced the localizer and glideslope indications for the instrument landing system (ILS) approach during the descent. The pilot stated that he had lowered the landing gear and extended the flaps when the engine “cut out.” He switched fuel tanks and attempted to restart the engine, but was unsuccessful, and he subsequently retracted the landing gear and performed a forced landing to the Susquehanna River. The airplane was submerged in the Susquehanna River until October 16, 2019, before it was recovered. Examination of the wreckage following recovery revealed that the airplane was intact, but the fuselage was deformed aft of the cabin door. Both wings were cut at their roots by recovery personnel. Before removal of the wings, each wing was drained of fuel and water. The left wing contained 12.5 gallons of fuel and 10 gallons of water. The right wing contained 17 gallons of fuel and 15 gallons of water. Flight control continuity was confirmed from the flight controls to all flight control surfaces. Fuel system continuity was confirmed from the roots of each wing to the fuel metering unit. Electrical power was applied to the fuel boost pumps in each wing, and both operated when energized. The engine spark plugs were removed from the top of each cylinder. Each spark plug displayed normal wear and evidence of exposure to water. The engine was rotated by hand at the propeller; both magneto impulse couplings "snapped," and spark was produced at the ignition leads of the top six spark plugs. The engine examination was suspended, and the engine was removed for examination at the manufacturer’s facility. Prior to placement in the test cell, some engine components required repair or replacement due to water submersion, damage, or contamination. The engine starting motor was replaced when rotation of the propeller revealed “binding.” Ignition timing was confirmed on the left and right magneto prior to removal for drying. Once dried, they were reinstalled and timed to their as-found timing values. Once placed in the test cell, an engine start was attempted without success. Investigation revealed that the fuel manifold was contaminated and blocked due to water submersion. The manifold was removed, disassembled, cleaned, reassembled,and reinstalled. An engine start was attempted, and the engine started immediately, accelerated smoothly, and ran continuously at all power settings without interruption. The examination and test run revealed no pre-impact anomalies that would have prevented the engine’s ability to produce rated horsepower. Examination of the airplane’s flight track and data downloaded from its engine data monitor revealed the airplane experienced an increase in lateral g-forces as it aligned with the final approach (localizer) course. The airplane continued its approach left of the localizer course in a right-wing down or slip configuration, consistent with compensation for the gusting wind from its right side. According to the pilot’s operating handbook for the airplane: Prolonged slips or skids which result in excess of 2000 feet of altitude loss or other radical or extreme maneuvers which could cause uncovering of the fuel outlet must be avoided as fuel flow interruption may occur when the tank being used is not full. ## Aircraft - Registration: [N4385K](https://openairdocs.org/deregistered/N4385K-2021-06-11), registration cancelled 2021-06-11, S/N 46-8508027, built 1984 (OpenAirDocs) - Reported make and model: Piper PA46 (310P) - Registry model: [Piper PA-46-310P](https://openairdocs.org/model/piper-pa-46-310p) (registry code 7104605) (OpenAirDocs) - Registry engine: [Continental GTSI0-520-F-K](https://openairdocs.org/engine/continental-gtsi0-520-f-k) (registry code 17031, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 46-8508027 - Year built: 1984 - Airframe hours: 5105 - Engines: Continental TSIO 550C 310 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 1, 2019, 20 hours before - Departed: ROC, Rochester, NY - Destination: MDT, Harrisburg, PA - Flight plan: IFR - Airport: MDT, Harrisburg Intl, runway 31, 10,001 × 200 ft, asphalt - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; injuries: minor; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; flight hours: 1,502 total, 433 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 10° at 9 knots, gusting 22 - Visibility: 10 statute miles - Temperature: 63 °F, dew point 43 °F - Altimeter: 30.20 inHg - Observed at: KMDT, 2 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 20191004018749A](https://openairdocs.org/incident/20191004018749A), Oct 4, 2019: Piper PA-46-310P, Lower Swatara T, PA, Substantial damage. Pilot departed kroc about 1600 hours on October 4 for the flight to kmdt. Pilot received initial clearance to 10,000' and was subsequently cleared to 12,000'… ## Docket (10 files) The files NTSB released with the investigation on June 16, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100432. 26.6 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 10 pages, 12.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9132874&FileExtension=pdf&FileName=ERA20LA011%20NTSB%206120%20(Pilot)_Redacted-Rel.pdf - AS-40 data review (item 2, PDF, 2 pages, 729 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11931400&FileExtension=pdf&FileName=ERA20LA011%20Data%20Review_Redacted-Rel.pdf - Engine tabular data (item 3, CSV, 666 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11933717&FileExtension=csv&FileName=Engine%20Tabular%20Databr-Rel.csv - Air traffic control radar tabular data (item 4, CSV, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11926318&FileExtension=csv&FileName=N4385K%20radar%20tabular%20data-Rel.csv - Powerplants report (NTSB) (item 5, PDF, 12 pages, 8.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11931428&FileExtension=pdf&FileName=Engine%20Examination%20-%20ERA20LA011_Redacted-Rel.pdf - Powerplants (cmg) (item 6, PDF, 11 pages, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11931410&FileExtension=pdf&FileName=CMG%20engine%20run%20report_Redacted-Rel.pdf - Pilot operating handbook excerpt (item 7, PDF, 1 page, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14023140&FileExtension=pdf&FileName=VB-1200%20Malibu%20Operating%20Tips%20-%20Slips-Rel.pdf - Statement of party representatives to NTSB investigation (item 8, PDF, 2 pages, 483 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11931570&FileExtension=pdf&FileName=Signed%20NTSB%20Party%20Letter%208-2017_Redacted-Rel.pdf - Evidence control form (item 9, PDF, 1 page, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11931420&FileExtension=pdf&FileName=Evidence%20Control%20Form%20LA011_Redacted-Rel.pdf - Photo array (item 10, PDF, 2 pages, 704 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14022580&FileExtension=pdf&FileName=Docket%20Array-Rel.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.