# NTSB ERA20LA309: Piper PA28, N4166Z, McMinnville, TN, September 8, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: September 8, 2020, 11:30 local (16:30 UTC) - Place: McMinnville, TN - Coordinates: 35.695278, -85.853614 - Nearby events: https://openairdocs.org/map.md?lat=35.6953&lon=-85.8536&mi=10 - Phase of flight: [Emergency descent](https://openairdocs.org/ntsb-phases/600) (OpenAirDocs' grouping) - Defining event: [Emergency descent: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Piper Aircraft, FAA/FSDO, Lycoming Engines - ADs cited in the narratives: [AD 2009-26-12](https://openairdocs.org/ad/2009-26-12) (OpenAirDocs) - NTSB case key (mKey): 101928 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20LA309 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101928/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101928 - Page: https://openairdocs.org/ntsb/ERA20LA309 ## Probable cause A total loss of engine power due to a fatigue failure in a cylinder, and the pilot’s subsequent failure to maintain airspeed and her exceedance of the airplane’s critical angle-of-attack while maneuvering at low altitude. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Fatigue/wear/corrosion (probable cause); cases with it: [Piper PA-28-181, 6 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=7102807), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-181, 53 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102807), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28-181, 7 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=7102807), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28-181, 7 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=7102807), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340); cases with it: [Piper PA-28-181, 4 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=7102807), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Piper PA-28-181, 26 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102807), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-28-181, 18 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102807), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Emergency descent: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Piper PA-28-181, 5 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=7102807), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-181, 70 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102807), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis During initial climb, below 500 ft above ground level, the engine experienced a total loss of power due to a separated cylinder head. The pilot initiated a right turn (based on the orientation of the wreckage) and the airplane stalled and spun flat into a field. Metallurgical examination of the cylinder revealed fatigue cracking, which was observed around approximately 180° of the cylinder circumference. The fatigue cracking emanated from the vertical stiffener on the front of the cylinder between the third and fourth fins. The fatigue cracking appeared to initiate at the start of the fillet between the vertical stiffener and the circumferential outer wall of the cylinder. The remainder of the fracture surface was consistent with overstress. The cylinder was installed new when the engine was overhauled about 19 months prior to the accident. The engine had accrued about 671 hours since overhaul. ## Factual narrative HISTORY OF FLIGHT On September 8, 2020, about 1130 central daylight time, a Piper PA-28-181, N4166Z, was substantially damaged when it was involved in an accident near McMinnville, Tennessee. The pilot and two passengers were fatally injured. The airplane was owned by Lebanon Flying Club and operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot flew uneventfully from Murfreesboro Municipal Airport (MBT), Murfreesboro, Tennessee, to Warren County Memorial Airport (RNC), McMinnville, Tennessee. Review of security video at RNC revealed that the airplane landed on runway 23 about 1123. It then taxied back to the beginning of the runway for takeoff about 1128 and disappeared from camera view during initial climb about 1 minute later. Smoke was observed emanating from the airplane before it travelled beyond camera view. A witness, who was walking in his backyard heard an airplane engine go silent, then heard the sound of an impact about 30 seconds later. During that time, he briefly saw the airplane through trees but could not determine its attitude. Review of radar data revealed targets consistent with the accident airplane arriving at RNC, but the airplane did not obtain enough altitude upon departure (about 500 ft above ground level) for any further radar data to be recorded. PILOT INFORMATION According to the pilot’s logbook, she received a flight review on February 23, 2020. The only other entry was dated August 20, 2020, when she satisfactorily completed a 1-hour checkout flight to use a flying club airplane. The next flight was the accident flight. AIRCRAFT INFORMATION The engine was overhauled by Continental Motor Services (CMS), Fairhope, Alabama on January 29, 2019. The engine was returned to CMS on September 10, 2019, at 300.45 hours since overhaul, for inspection due to a propeller strike. At the time of the accident, the engine had accrued 671.1 hours since overhaul during a period about 19 months. WRECKAGE INFORMATION Examination of the accident site by Federal Aviation Administration (FAA) inspectors and a representative from the airframe manufacturer revealed that the airplane came to rest flat and upright in a field about 1,000 ft northwest (45° right of runway departure end) of runway 23. All major components of the airplane were accounted for and remained intact. The engine was canted right, and the left side of the empennage exhibited buckling. The cabin roof had been separated by first responders. Three lapbelts were cut by first responders, but their ends remained attached to the respective fuselage attach points. Fuel remained in both wing fuel tanks, and the fuel selector was found positioned to the right main fuel tank. Flight control continuity was confirmed from the cockpit to all flight control surfaces and the flaps were retracted. Measurement of the pitch trim jackscrew corresponded to a partial nose-down trim setting. Examination of the engine revealed that the No. 4 cylinder head wasfractured circumferentially, exposing the top of the piston. The cylinder head was displaced horizontally from the crankcase such that the pushrods and pushrod tubes remained captured in the cylinder head but were dislodged from the crankcase. Metallurgical examination of the cylinder revealed a flat fracture with thumbnail-shaped arrest marks consistent with fatigue cracking, which was observed around approximately 180° of the cylinder circumference. The fatigue cracking emanated from the vertical stiffener on the front of the cylinder between the third and fourth fins. The fatigue cracking appeared to initiate at the start of the fillet between the vertical stiffener and the circumferential outer wall of the cylinder. The remainder of the fracture surface was consistent with overstress. The hardness of the cylinder material was measured on the designed flat on the intake side of the cylinder head near the barrel junction. The hardness of the cylinder material measured approximately 59 HB [Brinell hardness number]/10mm/500kgf [kilogram-force] (converted from 19.9 HRA [Rockwell A hardness number]). The hardness specified on the manufacturer drawing was 60-75 HB/10mm/500kgf. A portion of one cooling fin was sectioned from the cylinder and the chemical composition was determined using standardless semiquantitative energy dispersive spectroscopy. The measured weight percentages of the cylinder cooling fin material were within specifications when compared to the composition required in manufacturer material specifications. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by the State of Tennessee, Office of The Medical Examiner, Nashville, Tennessee. The cause of death was multiple blunt force injuries. Toxicology testing was performed on the pilot by the laboratory at FAA Forensic Sciences. The results revealed trimethoprim detected in blood and urine. Trimethoprim is an anti-infection medication and not considered impairing. ADDITIONAL INFORMATION The cylinder was manufactured in 2018 by Continental Aerospace Technologies (CAT), which acquired Engine Components International Division (ECi) in 2015. FAA Airworthiness Directive (AD) 2009-26-12), issued on February 4, 2010, affected 18,000 ECi cylinders regarding inspection and/or replacement due to cracks and cylinder head separation. The accident cylinder was not subject to the AD because it was manufactured after the AD was issued. Review of FAA service difficulty reports did not reveal any other cylinder head cracks or separations pertaining to cylinders manufactured after the AD was issued. ## Aircraft - Registration: [N4166Z](https://openairdocs.org/deregistered/N4166Z-2023-04-01), registration cancelled 2023-04-01, S/N 2843327, built 2000 (OpenAirDocs) - Reported make and model: Piper PA28 (181) - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2843327 - Year built: 2000 - Airframe hours: 2274.5 - Engines: Lycoming O360-A4M 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Lebanon Flying Club - Registered owner: Lebanon Flying Club - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 26, 2019, 358 hours before - Departed: RNC, McMinnville, TN - Destination: RNC, McMinnville, TN - Airport: RNC, Warren County Memorial, runway 23, 5,000 × 100 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review February 23, 2020; seat: left; restraint: lap only; toxicology performed; flight hours: 299 total, 170 in this make and model, 1 in the last 90 days, 1 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 200° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 63 °F - Altimeter: 30.09 inHg - Observed at: RNC, 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 20200908012119A](https://openairdocs.org/incident/20200908012119A), Sep 8, 2020: Piper PA-28-181, Mcminnville, TN, Destroyed, 3 fatal. Aircraft departed lebanon TN airport (M54) flying to Mcminnville, TN airport (rnc) landing at approximately 1120 local, taxied to runway 23 to takeoff.… ## Docket (12 files) The files NTSB released with the investigation on October 15, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101928. 135 MB in all. - FAA interview summaries (item 1, PDF, 2 pages, 303 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12053194&FileExtension=pdf&FileName=FAA%20Interviews_Redacted-Rel.pdf - Excerpts from pilot logbook (item 2, PDF, 3 pages, 11.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12807638&FileExtension=pdf&FileName=1_3_Pilot%20Logbook%20Excerpts_Redacted-Rel.pdf - Rnc aviation director statement (item 3, PDF, 1 page, 254 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12053579&FileExtension=pdf&FileName=RNC%20Aviation%20Director%20Statement_Redacted-Rel.pdf - Excerpts from maintenance recordsdd (item 4, PDF, 18 pages, 22.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12053569&FileExtension=pdf&FileName=Mx%20Excerpts_Redacted-Rel.pdf - Radar plot of arrival to rnc (item 5, PDF, 1 page, 435 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12053968&FileExtension=pdf&FileName=Radar%20Plot-Rel.pdf - Rnc security video of landing, taxi, and takeoff (6 minutes, 59 seconds long, wmv format, 93MB) (item 6, WMV, 95.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12053978&FileExtension=WMV&FileName=RNC%20Security%20Video-Rel.WMV - Map of accident site (item 7, PDF, 1 page, 209 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12054107&FileExtension=pdf&FileName=Map-Rel.pdf - Photo array (item 8, PDF, 4 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12054230&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Toxicological report (item 9, PDF, 1 page, 174 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12053204&FileExtension=pdf&FileName=Tox_Redacted-Rel.pdf - Materials laboratory factual report (item 10, PDF, 8 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12053988&FileExtension=pdf&FileName=21-006%20Materials%20Lab%20Factual%20Report%20(ERA20LA309)_revised%2025FEB2021-Rel.pdf - Statement of party representatives to NTSB investigation (item 11, PDF, 12 pages, 393 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12053589&FileExtension=pdf&FileName=Party%20Forms_Redacted-Rel.pdf - Wreckage release and evidence control form (item 12, PDF, 2 pages, 182 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12053892&FileExtension=pdf&FileName=Wreckage%20And%20Evidence_Redacted-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.