# NTSB ERA24LA109: Piper PA23, N1317P, Louisville, KY, February 1, 2024 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 4 · Limited · Final report - Date: February 1, 2024, 10:35 local (15:35 UTC) - Place: Louisville, KY · In flight near the LOU airport - Coordinates: 38.227984, -85.663749 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.2280&lon=-85.6637&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338) - Highest injury: No injuries - Injuries: 2 uninjured - 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 - NTSB case key (mKey): 193758 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA24LA109 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193758/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=193758 - Page: https://openairdocs.org/ntsb/ERA24LA109 ## Probable cause The failure of maintenance personnel to thoroughly inspect and repair the worn-out panel fasteners and fastener holes. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Misc hardware: fasteners](https://openairdocs.org/ntsb-findings/01071430): Aircraft › Fluids/misc hardware · Inadequate inspection (probable cause); cases with it: [Piper PA-23, 1 case](https://openairdocs.org/ntsb-findings/01071430/cases.md?model=7102302), [All aircraft, 58 cases](https://openairdocs.org/ntsb-findings/01071430/cases.md) - [Aircraft](https://openairdocs.org/ntsb-findings/01030000): Aircraft › Aircraft structures · Fatigue/wear/corrosion (probable cause); cases with it: [Piper PA-23, 1 case](https://openairdocs.org/ntsb-findings/01030000/cases.md?model=7102302), [All aircraft, 72 cases](https://openairdocs.org/ntsb-findings/01030000/cases.md) - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-23, 1 case](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=7102302), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft inspection event](https://openairdocs.org/ntsb-events/050); cases with it: [Piper PA-23, 3 cases](https://openairdocs.org/ntsb-events/050/sequence.md?model=7102302), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md) - [Initial climb: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338) (defining event); cases with it: [Piper PA-23, 2 cases](https://openairdocs.org/ntsb-events/338/sequence.md?model=7102302), [All aircraft, 563 cases](https://openairdocs.org/ntsb-events/338/sequence.md) - [Initial climb: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Piper PA-23, 3 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=7102302), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) ## 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](https://openairdocs.org/aircraft/N1317P), registered now, S/N 23-357, built 1955 (OpenAirDocs) - Reported make and model: PIPER PA23 (150) - Registry model: [Piper PA-23](https://openairdocs.org/model/piper-pa-23) (registry code 7102302) (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: 23-357 - Year built: 1955 - Airframe hours: 6417.6 - Engines: LYCOMING O-360-A1D 180 horsepower reciprocating; LYCOMING 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; injuries: none; 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 - Pilot-rated passenger; age 47; injuries: none; 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= ## 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 20240201001449A](https://openairdocs.org/incident/20240201001449A), Feb 1, 2024: Piper PA-23, Louisville, KY, Substantial damage. Aircraft departed runway 24 at Louisville Bowman field (klou). During climb-out, aircraft made a right-crosswind turn climbing to approximately 1,400 ft MSL.… ## Other investigations on N1317P (1) 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. - [NTSB UNK64X1363](https://openairdocs.org/ntsb/UNK64X1363), Apr 18, 1964: Piper PA23 (N1317P), Santa Ana, CA, no damage ## Docket (7 files) The files NTSB released with the investigation on June 13, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=193758. 9.9 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17175971&FileExtension=pdf&FileName=01%20Pilot%206120%20form_redacted-Rel.pdf - Mor - pilot preflight question (item 2, PDF, 1 page, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17175867&FileExtension=pdf&FileName=02%20MOR%20-%20Pilot%20Preflight%20Question-Rel.pdf - Mor - pilot rated passenger statement (item 3, PDF, 1 page, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17175529&FileExtension=pdf&FileName=03%20Pilot%20rated%20passenger%20statement-Rel.pdf - Mor - pilot rated passenger preflight question (item 4, PDF, 1 page, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17175166&FileExtension=pdf&FileName=04%20Pilot%20Rated%20Passenger%20Preflight%20MOR-Rel.pdf - Mor - mechanic interview (item 5, PDF, 1 page, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17175493&FileExtension=pdf&FileName=05%20MOR%20-%20Mechanic%20Questions-Rel.pdf - Maintenance logbook excerpt (item 6, PDF, 3 pages, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17175702&FileExtension=pdf&FileName=06%20Maintenance%20Logbook%20Excerpt_Redacted-Rel.pdf - Investigation photographs (item 7, PDF, 8 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17175539&FileExtension=pdf&FileName=07%20Investigation%20Photographs-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.