# NTSB ERA22LA169: Diamond Aircraft Ind DA 40 NG, N471BL, Smithfield, NC, March 25, 2022

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Class 3 · Limited · Final report
- Date: March 25, 2022, 16:13 local (20:13 UTC)
- Place: Smithfield, NC
- Coordinates: 35.527596, -78.381851 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=35.5276&lon=-78.3819&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341)
- Highest injury: Serious injuries
- Injuries: 2 serious
- 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
- NTSB case key (mKey): 104831
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA22LA169
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104831/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104831
- Page: https://openairdocs.org/ntsb/ERA22LA169

## 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

NTSB's coded findings; those marked are part of the probable cause.

- [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Maintenance personnel (probable cause); cases with it: [Diamond Aircraft Ind DA 40 NG, 3 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=2990014), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md)
- [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Diamond Aircraft Ind DA 40 NG, 2 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=2990014), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md)
- [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Diamond Aircraft Ind DA 40 NG, 2 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=2990014), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Diamond Aircraft Ind DA 40 NG, 4 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2990014), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md)
- [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Diamond Aircraft Ind DA 40 NG, 3 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2990014), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md)

## 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](https://openairdocs.org/aircraft/N471BL), registered now, S/N 40.NC111, built 2020 (OpenAirDocs)
- Reported make and model: DIAMOND AIRCRAFT IND INC DA 40 NG
- Registry model: [Diamond Aircraft Ind DA 40 NG](https://openairdocs.org/model/diamond-aircraft-ind-da-40-ng) (registry code 2990014) (OpenAirDocs)
- Registry engine: [Austro E4-A](https://openairdocs.org/engine/austro-e4-a) (registry code 06402, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 40.NC111
- Year built: 2020
- Airframe hours: 895
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Flight instructor; age 20; injuries: serious; flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1; seat: right; restraint: 3-point
- Pilot; age 26; injuries: serious; 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

## 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 20220325002279A](https://openairdocs.org/incident/20220325002279A), Mar 25, 2022: Diamond Aircraft Ind Inc DA 40 NG, Smithfield, NC, Destroyed. On March 25, 2022 at approximately 16:15 EDT local time, N471BL crashed 2 miles south of the jnx airport. The aircraft suffered a complete loss of engine power…

## Docket (10 files)

The files NTSB released with the investigation on October 19, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104831. 37.3 MB in all.

- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 5 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15303176&FileExtension=pdf&FileName=471BL-%20NTSB%20Report_optr_Redacted-Rel.pdf
- Pilot statements (item 2, PDF, 2 pages, 439 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15303457&FileExtension=pdf&FileName=Pilot%20Statements%20(2)_Redacted-Rel.pdf
- Maintenance log excerpts (item 3, PDF, 5 pages, 26.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15460774&FileExtension=pdf&FileName=Engine%20Logbook%20Excerpts_Redacted-Rel.pdf
- Investigative photographs (item 4, PDF, 3 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15303612&FileExtension=pdf&FileName=ERA22LA169%20Investigative%20Photographs-Rel.pdf
- Memorandum of record engine examination (item 5, PDF, 6 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15461767&FileExtension=pdf&FileName=ERA22LA169%20Engine%20Examination-Rel.pdf
- Flight data recorder - specialist's factual report-ERA22LA169 (item 6, PDF, 12 pages, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14452345&FileExtension=pdf&FileName=Flight%20Data%20Recorder%20-%20Specialist%27s%20Factual%20Report-ERA22LA169-Rel.pdf
- Attachment 1 to flight data recorder - specialist's factual report (item 7, CSV, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14451867&FileExtension=csv&FileName=Attachment%201%20to%20Flight%20Data%20Recorder%20-%20Specialist%27s%20Factual%20Report-Rel.csv
- Engine control unit - specialist's factual report_ERA22LA169 (item 8, PDF, 7 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14452223&FileExtension=pdf&FileName=Engine%20Control%20Unit%20-%20Specialist%27s%20Factual%20Report_ERA22LA169-Rel.pdf
- Attachment 1 to engine control unit - specialist's factual report (item 9, CSV, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14452355&FileExtension=csv&FileName=Attachment%201%20to%20Engine%20Control%20Unit%20-%20Specialist%27s%20Factual%20Report-Rel.csv
- Release of aircraft wreckage, NTSB form 6120.15 (item 10, PDF, 1 page, 744 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15477541&FileExtension=pdf&FileName=NTSB%20Release_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.

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