# NTSB ERA23LA112: Piper PA-31-350, N101MA, Middlefield, OH, January 18, 2023 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: January 18, 2023, 09:03 local (14:03 UTC) - Place: Middlefield, OH - Coordinates: 41.449596, -81.062934 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.4496&lon=-81.0629&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) - Highest injury: No injuries - Injuries: 6 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Lycoming, FAA FSDO - NTSB case key (mKey): 106591 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA23LA112 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106591/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=106591 - Page: https://openairdocs.org/ntsb/ERA23LA112 ## Probable cause A runway overrun during a precautionary landing following a total loss of right engine power due to detonation and subsequent oil starvation. Contributing was the pilot’s failure to lower the flaps and the excessive airspeed at touchdown. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: surface speed/braking](https://openairdocs.org/ntsb-findings/01062045): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Piper PA-31-350, 1 case](https://openairdocs.org/ntsb-findings/01062045/cases.md?model=7103110), [All aircraft, 238 cases](https://openairdocs.org/ntsb-findings/01062045/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-31-350, 13 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7103110), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-31-350, 1 case](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=7103110), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-31-350, 2 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7103110), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Flight control system: tE flap control system](https://openairdocs.org/ntsb-findings/01022750): Aircraft › Aircraft systems · Not used/operated; cases with it: [Piper PA-31-350, 1 case](https://openairdocs.org/ntsb-findings/01022750/cases.md?model=7103110), [All aircraft, 74 cases](https://openairdocs.org/ntsb-findings/01022750/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Piper PA-31-350, 3 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7103110), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Piper PA-31-350, 8 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7103110), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## Analysis While enroute in instrument meteorological (IMC) conditions, the pilot of the twin-engine, piston-powered airplane declared an emergency following a loss of power to the right engine. The pilot secured the engine and was provided vectors by air traffic control for an instrument approach procedure at the nearest airport, which he successfully completed. The pilot reported that he flew the approach and landing with the wing flaps retracted and visually acquired the runway about 500 ft above the ground. The airplane touched down on the first third of the runway at 120 knots. The pilot knew he would not be able to stop the airplane on the 3,500-ft-long runway but committed to the landing rather than risking a single-engine go-around in IMC. After landing, the airplane continued beyond the departure end of the runway and impacted a berm, collapsing the landing gear and resulting in substantial damage to the airplane. Examination of the engine revealed catastrophic damage consistent with detonation and oil starvation. The damage to the No. 5 cylinder was consistent with a subsequent overpressurization of the crankcase, which likely expelled the crankshaft nose seal and the oil supply. Detonation of the cylinder(s) can create excessive crankcase pressures capable of expelling the crankshaft nose seal. The crankshaft nose seal displacement likely created a rapid loss of oil and the resulting oil starvation of the engine. The fractured connecting rod and high-temperature signatures were consistent with oil starvation. No source or anomaly that would result in engine detonation was identified. According to the Pilot’s Operating Handbook (POH) for the accident airplane, during a single-engine inoperative approach, the pilot should maintain an airspeed of 116 kts indicated (KIAS) or above until landing is assured. Once landing is assured, the pilot should extend the gear and flaps, slowly retard the power on the operative engine, and land normally. The airplane’s best single-engine rate of climb speed (blue line) was 106 KIAS, and its minimum controllable airspeed with one engine inoperative (Vmca) was 76 KIAS. The maximum speed for full flap extension (40°) was 132 KIAS. The POH also stated that a single-engine go-around should be avoided if at all possible. The pilot’s decision to commit to the landing was reasonable given the circumstances and the guidance provided by the POH; however, it is likely that his decision to conduct the landing without flaps and the airplane’s excessive airspeed at touchdown resulted in the runway overrun. ## Factual narrative On January 18, 2023, at 0903 eastern standard time, a Piper PA-31-350, N101MA, was substantially damaged when it was involved in an accident at Geauga County Airport (7GA), Middlefield, Ohio. The airline transport pilot and five passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 135 non-scheduled passenger flight. The purpose of the flight was to pick up a sixth passenger in Detroit, Michigan, before continuing to Minneapolis, Minnesota. As the airplane climbed through about 6,000 ft mean sea level (msl) in instrument meteorological conditions (IMC), the pilot observed oil leaking from the right engine nacelle. When the airplane reached about 7,400 ft msl, the pilot noted a loss of right engine power. He secured the engine, declared an emergency, requested to divert to the closest airport, and the air traffic controller vectored the airplane for the RNAV RWY 11 approach at 7GA. The pilot successfully completed the approach and reported that the airplane touched down in the “first one-third” of the landing runway at an airspeed “about 120 knots with zero flaps.” The pilot reported to a Federal Aviation Administration (FAA) inspector that he visually acquired the runway about 500 ft above the ground and knew he would not stop the airplane before it reached the departure end of the 3,500-ft-long runway, but chose to continue rather than abort the landing with one engine inoperative and climb the airplane back into IMC for another instrument approach. The airplane overran the departure end of the runway, continued through the grass overrun, and impacted a hill and a fence before coming to rest upright about 600 ft beyond the runway end. All three landing gear collapsed and the airplane sustained substantial damage to the wings and fuselage. According to FAA and maintenance records, the airplane was manufactured in 1977 and was powered by two Lycoming TIO-540-J2BD, 350-horsepower engines. The airplane’s most recent 100-hour inspection was completed on December 12, 2022, at 17,154.5 total aircraft hours, which was 42 hours before the accident. The right engine had accrued 1,662.5 total hours since major overhaul. Examination of photographs revealed substantial wrinkling of the fuselage and both wings as well as torn flight control surfaces. The right engine cowling was opened and examination revealed cracks in the engine crankcase. The engine was removed and examined at a local aircraft technician’s school. A large crack in the crankcase was visible above the No. 5 cylinder and the crankshaft nose seal was found partially displaced. Oil streaks originated from that point and covered the engine case. Oil streaking was also visible on the right engine cowling at the scene. Crankshaft rotation attempts were unsuccessful. Borescope examination of the No. 5 cylinder revealed damage consistent with detonation. The remaining cylinders did not appear to have the same extensive damage via the borescope.Attempts to remove the No. 5 cylinder were unsuccessful. Removal of the No. 3 cylinder showed minor detonation signatures in the combustion chamber and on the piston. The No. 5 cylinder was then removed, and the connecting rod was found broken at the large bearing end. Excessive heat and oil starvation signatures were observed at the connecting rod end. The partially-melted piston was removed from the No. 5 cylinder and a large crater was observed in the combustion chamber from the exhaust valve to the spark plug hole. Attempts to rotate the crankshaft with the two cylinders removed were unsuccessful, likely due oil starvation and heat damage to the crankshaft. The remaining rocker box covers were removed for visual examination with no discrepancies noted. The spark plugs displayed an “excessively rich mixture” coloration and were sent to Lycoming engines for analysis in their materials lab. The top spark plug from the No. 5 cylinder displayed a “badly damaged” insulator. When asked, the Lycoming engines representative said that detonation events are typically associated with a lean fuel mixture, and the damage displayed was the likely the result of detonation in the No. 5 cylinder. No source or anomaly that would result in engine detonation was identified. According to the Pilot’s Operating Handbook (POH) for the accident airplane, during a single-engine inoperative approach, the pilot should maintain an airspeed of 116 kts indicated (KIAS) or above until landing is assured. Once landing is assured, the pilot should extend the gear and flaps, slowly retard the power on the operative engine, and land normally. The airplane’s best single-engine rate of climb speed (blue line) was 106 KIAS, and its minimum controllable airspeed with one engine inoperative (Vmca) was 76 KIAS. The maximum speed for full flap extension (40°) was 132 KIAS. The POH also stated that a single-engine go-around should be avoided if at all possible. ## Aircraft - Registration: [N101MA](https://openairdocs.org/aircraft/N101MA), registered now, S/N 31-7752186, built 1977 (OpenAirDocs) - Reported make and model: PIPER PA-31-350 - Registry model: [Piper PA-31-350](https://openairdocs.org/model/piper-pa-31-350) (registry code 7103110) (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: 31-7752186 - Year built: 1977 - Airframe hours: 17154 - Engines: Lycoming TIO-540-J2BD 350 horsepower reciprocating; Lycoming TIO-540-J2BD 350 horsepower reciprocating - Damage: Substantial damage - Flight: Business, Part 135 - Operator: Pablo Air Charters LLC - Registered owner: Pablo Air Charters LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, December 12, 2022, 42 hours before - Departed: KYNG, Youngstown, OH - Destination: Same as departure - Flight plan: IFR - Airport: 7G8, Geauga County, runway 11, 3,500 × 65 ft, asphalt - Equipment: Auto-pilot, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 67; injuries: none; flight instructor, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review June 29, 2022; seat: left; flight hours: 9,275 total, 750 in this make and model, 8,965 as pilot in command, 155 in the last 90 days, 76 in the last 30 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 260° at 6 knots - Visibility: 0.5 statute miles - Lowest ceiling: 1,000 ft overcast - Temperature: 36 °F, dew point 32 °F - Altimeter: 29.97 inHg - Observed at: POV, 16 nm away - METAR: METAR KPOV 181415Z AUTO 26006KT 2 1/2SM OVC010 02/00 A2997 RMK AO2 T00220000 PWINO= ## 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 20230118001569A](https://openairdocs.org/incident/20230118001569A), Jan 18, 2023: Piper PA-31-350, Middlefield, OH, Substantial damage. [privacy data omitted] Departed kyng (youngstown/ warren regional airport) enroute to kyip (willow run airport). During the climb around 6000 feet the pilot… ## Docket (7 files) The files NTSB released with the investigation on October 3, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=106591. 11.5 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 10 pages, 5.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17360037&FileExtension=pdf&FileName=Reprt%20to%20NTSB-1-21-23_Redacted-Rel.pdf - Memorandum for record a�� telephone interview, pilot (FAA) (item 2, PDF, 1 page, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17348186&FileExtension=pdf&FileName=RE_%20ERA23LA112%20Middlefield,%20OH%20Pilot%20Interview%20Summary_Redacted-Rel.pdf - Memorandum for record a�� telephone interview, pilot summary (item 3, PDF, 1 page, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17352041&FileExtension=pdf&FileName=FAA%20ROC%20with%20Pilot_Redacted-Rel.pdf - Pilot operating handbook excerpts (item 4, PDF, 4 pages, 279 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17352343&FileExtension=pdf&FileName=PA-31-350%20POH%20Excerpts-Rel.pdf - Photo array (item 5, PDF, 7 pages, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17353149&FileExtension=pdf&FileName=ERA23LA112%20Middlefield,%20Ohio%20Photo%20Array-Rel.pdf - FAA ac 33.47-1 (item 6, PDF, 6 pages, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17353193&FileExtension=pdf&FileName=AC_33_47-1-Rel.pdf - Memorandum for record Lycoming engines (item 7, PDF, 2 pages, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17355303&FileExtension=pdf&FileName=Memorandum%20for%20Record%20Russell%20Gait%20Lycoming%20Engines-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.