ERA22LA169

NTSB accident investigation · Diamond Aircraft Ind DA 40 NG · Smithfield, NC · March 25, 2022

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
March 25, 2022, 16:13 local (20:13 UTC)
Place
Smithfield, NC
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N471BLDiamond Aircraft Ind DA 40 NG
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
Diamond Aircraft Industries, Federal Safety Investigation Authority, FAA-FSDO, Austro Engines, Transportation Safety Board of Canada
FAA report
20220325002279A
Case key
104831

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

Maintenance personnel’s failure to set the correct engine timing after the replacement of a cylinder head and exhaust camshaft before the accident flight, which resulted in a total loss of engine power.

Findings · 3

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.

Action: incorrect action performancePersonnel issues › Action/decision · Maintenance personnelDiamond Aircraft Ind DA 40 NG: 3 casesAll aircraft: 1,386 casesProbable cause
Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · Incorrect service/maintenanceDiamond Aircraft Ind DA 40 NG: 2 casesAll aircraft: 373 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

According to the flight instructor, shortly after takeoff, she heard a “weird” noise coming from the engine and noted a drop in engine rpm. The flight instructor directed the pilot receiving instruction to turn back toward the airport; however, the engine lost all power, and the airplane impacted trees about 1 mile from the departure end of the runway. The airplane sustained substantial damage to the wings, fuselage, and empennage. A postaccident examination of the engine revealed that the engine valvetrain was not timed correctly and that the misalignment resulted in a piston striking a valve. The valve head had separated and fallen into the cylinder, resulting in the total loss of engine power. Examination of the maintenance logbooks revealed that the cylinder head and exhaust camshaft had been replaced the day before the accident flight. Thus, it is likely that the engine’s timing was not set correctly after this maintenance.

Factual narrative

On March 25, 2022, about 1613 eastern daylight time, a Diamond DA-40NG, N471BL, was substantially damaged when it was involved in an accident near Johnston Regional Airport (JNX), Smithfield, North Carolina. The flight instructor and pilot receiving instruction were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the flight instructor and pilot receiving instruction, they conducted a preflight inspection of the airplane, with no anomalies noted, before departing from runway 21 at JNX. Review of radar data revealed that the airplane climbed to an altitude of about 650 ft while turning left. The flight instructor stated that she “heard a weird noise come from the engine” and saw the rpm gauge drop. Shortly afterward, the flight instructor directed the pilot receiving instruction to turn back to the airport, and the engine lost total power while in the turn. The flight instructor attempted to restart the engine while the airplane descended but was unsuccessful. The airplane subsequently impacted trees about 1 mile from the departure end of the runway, resulting in substantial damage to the fuselage. In addition, both wings and the empennage were fractured from the impact. A postaccident examination of the engine revealed that engine valvetrain was not timed correctly and that the resulting misalignment resulted in the piston striking the valve. The valve head had subsequently separated and fallen into the cylinder. Examination of the maintenance logbooks revealed that the cylinder head and exhaust camshaft had been replaced the day before the accident flight.

Aircraft

Registration
N471BL
Reported as
Diamond Aircraft Ind DA 40 NG
Category
Airplane
Serial number
40.NC111
Built
2020
Airframe hours
895
Engine
Austro E4-A, 165 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Blue Line Aviation LLC
Registered owner
Blue Line Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 24, 2022 · 2.7 hours before
Airport
JNX · Johnston Regional Airport
Equipment
Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display, Onboard weather, Stall warning system, ADS-B, Auto-pilot, Data recorder

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
20
Injuries
Serious
Certificate
Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1
Seat
Right
Restraint
3-point
Role
Pilot
Age
26
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1
Last flight review
March 22, 2022
Seat
Left
Restraint
3-point

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 8 knots, gusting 18
Visibility
10 statute miles
Lowest ceiling
10,000 ft broken
Temperature
68 °F, dew point 32 °F
Altimeter
29.70 inHg
Observed at
JNX, 1 nm away
METAR
KJNX 252015Z AUTO 26008G18KT 10SM BKN100 20/00 A2970 RMK AO2

Docket · 10

The files NTSB released with the investigation on October 19, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 37.3 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.