ERA24LA109

NTSB accident investigation · Piper PA23 · Louisville, KY · February 1, 2024

Accident · No injuriesClass 4 · LimitedFinal report
Date
February 1, 2024, 10:35 local (15:35 UTC)
Place
Louisville, KY · In flight near the LOU airport
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N1317PPiper PA23
Defining event
Initial climb: Part(s) separation from AC
Weather
Visual (VMC) · Not reported
Status
Completed
Report
Approved by Office Director
Investigation class
Class 4 - Basic report with no Prelim publish
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20240201001449A
Case key
193758

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

The failure of maintenance personnel to thoroughly inspect and repair the worn-out panel fasteners and fastener holes.

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.

Misc hardware: fastenersAircraft › Fluids/misc hardware · Inadequate inspectionPiper PA-23: 1 caseAll aircraft: 58 casesProbable cause
AircraftAircraft › Aircraft structures · Fatigue/wear/corrosionPiper PA-23: 1 caseAll aircraft: 72 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelPiper PA-23: 1 caseAll aircraft: 167 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

After recently completed maintenance, and the pilot and pilot-rated passenger decided to take the airplane for a test flight. Both occupants reported that a preflight inspection was completed and that no anomalies were noted during the preflight. Shortly after takeoff, the pilot and passenger noticed that a large part of the right engine nacelle cover had departed from the airplane. They requested to return to land at the airport and made a subsequent uneventful landing. The pilot reported that there were no adverse control issues observed during the return for landing. A subsequent inspection of the airplane revealed that the nacelle panel had impacted the right side of the horizontal stabilizer, resulting in substantial damage. Postaccident examination of the right engine nacelle revealed that most of the inspection panel had separated from the nacelle and was not located; however, a small portion of the outboard section of the panel remained attached to the engine nacelle. The remaining portion of the panel displayed significant wear around the camlock and screw retention holes; at least one of the retention screw holes was significantly larger than the retention screw head. While the missing portion of the of the inspection panel was not available for examination, it is likely that the screw holes on this portion were similarly worn. This wear should have been apparent to maintenance personnel when inspecting the airplane (but likely would have been obscured by the engine cowling and not visible during a pilot’s preflight inspection). Based on this information, it is likely, that when exposed to high airflow during departure, a portion of the panel pulled out of the retention fasteners and was pulled out into the airstream, resulting in most of the panel being torn from the airframe.

Aircraft

Registration
N1317P
Reported as
Piper PA23 (150)
Category
Airplane
Serial number
23-357
Built
1955
Airframe hours
6,417.6
Engines
Lycoming O-360-A1D, 180 horsepower, reciprocatingLycoming O-360-A1D, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Flight test · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 29, 2023 · 1 hours before
Departed
LOU · Louisville, KY
Airport
LOU · Bowman Fld
Equipment
ADS-B

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
Pilot
Age
53
Injuries
None
Certificates
Flight engineer, Airline transport, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land, Single-engine sea, Multi-engine sea
Instrument ratings
Airplane, Helicopter
Medical
Class 1, Without waivers/limitations
Last flight review
August 17, 2023
Seat
Right
Restraint
Lap only
Flight hours
14,000 total · 20 in this make and model · 6,000 as pilot in command · 80 in the last 90 days · 30 in the last 30 days · 1 in the last 24 hours
Role
Pilot-rated passenger
Age
47
Injuries
None
Certificates
Remote, Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
August 15, 2023
Seat
Left
Restraint
Lap only
Flight hours
12,000 total

Weather

Conditions
Visual (VMC) · Not reported
Wind
170° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
37 °F, dew point 32 °F
Altimeter
30.12 inHg
Observed at
LOU
METAR
METAR KLOU 011453Z 17008KT 10SM CLR 03/00 A3012 RMK AO2 SLP204 T00330000 58009=

Docket · 7

The files NTSB released with the investigation on June 13, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.9 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.

Other investigations on N1317P · 1

Matched to the same aircraft by N-number and date.