# NTSB ERA20LA290: Piper PA32, N4089R, Tallahassee, FL, August 19, 2020 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: August 19, 2020, 12:15 local (16:15 UTC) - Place: Tallahassee, FL - Coordinates: 30.409444, -84.358329 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.4094&lon=-84.3583&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff-rejected takeoff: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Minor injuries - Injuries: 1 minor, 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Lycoming Engines, FAA/FSDO - NTSB case key (mKey): 101827 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20LA290 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101827/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101827 - Page: https://openairdocs.org/ntsb/ERA20LA290 ## Probable cause A partial loss of engine power on takeoff due to an intermittently blocked fuel injector on the number 3 cylinder. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine fuel and control: fuel injector nozzle](https://openairdocs.org/ntsb-findings/01057313): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [Piper PA-32-300, 1 case](https://openairdocs.org/ntsb-findings/01057313/cases.md?model=7103212), [All aircraft, 20 cases](https://openairdocs.org/ntsb-findings/01057313/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff-rejected takeoff: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Piper PA-32-300, 10 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7103212), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Landing: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Piper PA-32-300, 7 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=7103212), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) - [Landing-landing roll: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490); cases with it: [Piper PA-32-300, 7 cases](https://openairdocs.org/ntsb-events/490/sequence.md?model=7103212), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) ## Analysis The pilot performed a preflight inspection of the airplane with no anomalies noted; during the engine run-up, the engine backfired. The pilot continued the run-up procedures and did not have any other issues with the engine. After rotation, the pilot noticed that the tachometer did not indicate full engine rpm, and also noted that the engine was not producing power. Since the airspeed was slow, he attempted to decrease the pitch of the airplane; however, the airplane was already in an aerodynamic stall, which resulted in impact with the runway. The airplane departed the right side of the runway and impacted the visual approach light system lights, resulting in substantial damage to the right wing. A postaccident examination and test run of the engine revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. A review of data extracted from the airplane’s engine data monitor data revealed that the number 3 cylinder began performing erratically beginning around 7 minutes after the recording began, likely as the airplane was being taxied, and continued through the run-up described by the pilot. This erratic behavior initially appeared as rapid increases and decreases in exhaust gas temperature (EGT) that differed dramatically from the behavior of the other 5 cylinders. Then, about 3 minutes after the erratic EGT temperatures began, the number 3 cylinder head temperature (CHT) began steadily decreasing, while the remaining 5 cylinders continued their gradual increase. The takeoff likely began about 11 minutes and 30 seconds after the data recording began, as the engine rpm increased to about 2,400 (which was less than the maximum 2,700 rpm that was observed during the three previous takeoffs that were recorded). Given this information, the most likely explanation for the observed EGT and CHT behaviors was that the number 3 cylinder fuel injector was being intermittently blocked. As the fuel mixture leaned due to the blockage, it produced the spikes observed in EGT, and the blockage eventually progressed to a point where the cylinder was no longer producing power, resulting in the observed gradual CHT cooling. Postaccident examination of the number 3 cylinder fuel injector showed that it was absent of debris and deposits; therefore, the nature and origin of the blockage could not be definitively determined. ## Factual narrative On August 19, 2020, about 1215 eastern daylight time, a Piper PA-32-300, N4089R, was substantially damaged when it was involved in an accident at Tallahassee International Airport (TLH), Tallahassee, Florida. The pilot incurred minor injuries and the two passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he performed a preflight inspection of the airplane with no anomalies noted and loaded the airplane for the flight. He knew that the airplane had about 60 gallons of fuel on board, since he flew a trip the previous week and used the fuel out of the left main tank. He performed the accident flight with the right main fuel tank selected. The engine started up, ran without issue, until the engine run-up when it "backfired." The pilot continued to perform the engine run-up by checking the magnetos and letting the engine continue to run, and no other issues were noted. The pilot taxied onto the runway and slowly increased engine power. After rotation, the pilot noticed that the tachometer did not indicate full engine rpm, and also noted that the engine was not producing power. Since the airspeed was slow and close to the stall speed, the pilot attempted to descend in order to increase the airspeed; however, the airplane was "already stalling." It "pancaked" onto the runway and veered off the right side striking the visual approach lighting system with the right wing. During the accident sequence, the right wing incurred substantial damage. After the accident, the pilot provided a weight and balance calculation for the flight, which revealed that the airplane was within load limits for the flight. An engine examination was performed by an NTSB investigator after the accident. The top spark plugs were removed from the engine and no anomalies were observed with their electrodes. The crankshaft was rotated by hand and valvetrain continuity was confirmed to the rear accessory section. Additionally, thumb compression was confirmed on all cylinders. The number 3 cylinder fuel injector was examined and found to be absent of debris or deposits. Fuel was plumbed from an external fuel tank into the engine. The engine started immediately, accelerated smoothly, and ran continuously without interruption. The airplane was equipped with a JPI EDM-700 engine data monitor. Examination of data from the unit revealed that the recording associated with the accident flight began around 1207. The exhaust gas temperatures (EGT) for all six cylinders followed rough relative patterns of increase and decrease until about 1214:30, when the number 3 cylinder EGT began intermittently rapidly increasing and decreasing until just before 1217. Also during this time the cylinder head temperatures (CHT) for all six cylinders gradually rose at a relatively uniform rate until from the start of the data until about 1217, when the number 3 CHT began a steady decrease while the remaining 5cylinders continued their gradual increase in temperature. About 1218, the engine rpm increased gradually over about 30 seconds to about 2,300, then reached a maximum of about 2,400 rpm shortly after 1219. The rpm then rapidly decreased around 1930. Review of 3 previous flights revealed that the engine rpm maximum recorded was about 2,700 rpm, compared to 2,400 achieved during the accident flight. ## Aircraft - Registration: [N4089R](https://openairdocs.org/deregistered/N4089R-2021-03-12), registration cancelled 2021-03-12, S/N 32-40408, built 1967 (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: 32-40408 - Year built: 1967 - Airframe hours: 5441 - Engines: Lycoming IO-540-K1A5 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 2, 2019 - Departed: TLH, Tallahassee, FL - Destination: FPR, Fort Pierce, FL - Flight plan: IFR - Airport: TLH, Tallahassee Intl, runway 36, 7,000 × 150 ft, asphalt - Equipment: Onboard weather, Handheld GPS, ADS-B, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; injuries: minor; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review October 21, 2019; seat: left; flight hours: 922 total, 862 in this make and model, 920 as pilot in command, 43 in the last 90 days, 6 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 20,000 ft broken - Temperature: 82 °F, dew point 75 °F - Altimeter: 29.90 inHg - Observed at: TLH, 1 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 20200819012839A](https://openairdocs.org/incident/20200819012839A), Aug 19, 2020: Piper PA-32-300, Tallahassee, FL, Substantial damage. On August 19, 2020, at 1135 EDT, a Piper PA-32-300, N4089R, registered to [privacy data omitted], stalled shortly after rotation at approximately 50FT altitude… ## Docket (14 files) The files NTSB released with the investigation on August 29, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101827. 407 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 5.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11358985&FileExtension=pdf&FileName=LA290%206120%20Docket_Redacted-Rel.pdf - Weight and balance calculation for accident flight (item 2, PDF, 2 pages, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11359185&FileExtension=pdf&FileName=LoadingSummary-Rel.pdf - Engine maintenance log excerpt (item 3, PDF, 5 pages, 85.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11360092&FileExtension=pdf&FileName=Pages%20from%20N4089R%20ENGINE%20LOG_Redacted-Rel.pdf - GPS factual report (item 4, PDF, 3 pages, 405 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11361025&FileExtension=pdf&FileName=ERA20LA290%20Garmin%20Factual%20Report-Rel.pdf - GPS factual report - attachment 1 (item 5, XLSX, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11360741&FileExtension=xlsx&FileName=ERA20LA290%20GPS%20Download%20Attachment%201-Rel.xlsx - Engine data monitor factual report (item 6, PDF, 5 pages, 748 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11360521&FileExtension=pdf&FileName=ERA20LA290%20JPI%20Factual%20report-Rel.pdf - Engine data monitor factual report - attachment 1 (item 7, CSV, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11361035&FileExtension=csv&FileName=ERA20LA290%20JPI%20Report%20Attachment%201-Rel.csv - Engine examination summary (item 8, PDF, 1 page, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11361320&FileExtension=pdf&FileName=NTSB%20Engine%20Examination%20Summary%20LA290-Rel.pdf - Video of post accident engine run (item 9, AVI, 314 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11361899&FileExtension=AVI&FileName=MVI_0949-Rel.AVI - Engine data monitor image of previous flight data (item 10, PDF, 1 page, 240 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11387476&FileExtension=pdf&FileName=3%20previous%20Flights%20Plus%20Accident%20Flight-Rel.pdf - Engine data monitor - 3 previous flights and accident flight - tabular data (item 11, CSV, 462 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11387585&FileExtension=csv&FileName=Three%20Previous%20Flights%20Plus%20Accident%20Flight%20-%20Tabular%20Data-Rel.csv - Investigative photographs (item 12, PDF, 2 pages, 2 photos, 250 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11360793&FileExtension=pdf&FileName=Photo%20Array%20LA290-Rel.pdf - Statement of party representatives to NTSB investigation (item 13, PDF, 9 pages, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11388137&FileExtension=pdf&FileName=N4089R%20Lycoming%20Party%20Form_Redacted-Rel.pdf - Evidence control form (item 14, PDF, 1 page, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11393795&FileExtension=pdf&FileName=Evidence-Control-Form%20LA290%20GPS%20and%20JPI-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.