ERA24LA392

NTSB accident investigation · Piper PA28 · LaGrange, GA · September 23, 2024

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
September 23, 2024, 14:42 local (18:42 UTC)
Place
LaGrange, GA
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N4298VPiper PA28
Defining event
Initial climb: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report October 22, 2025
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Lycoming Engines
Case key
195170

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

Improper manufacture of a cylinder exhaust valve guide by the engine manufacturer, which resulted in a stuck exhaust valve and a partial loss of engine power during initial climb.

Findings · 2

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.

Manufacture/production: equipment manufactureOrganizational issues › Development · ManufacturerPiper PA-28-161: 1 caseAll aircraft: 36 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

The flight instructor and student pilot had completed maneuvers over the local area before the student pilot performed a touch-and-go landing. During initial climb after the touch-and-go landing, about 200 to 300 ft above ground level, the engine began to run rough and the airplane stopped climbing. The flight instructor then took control of the airplane from the student pilot and made a right turn for a forced landing on a perpendicular runway. The flight instructor stated that during the landing attempt, the engine power did not reduce to idle when the instructor pulled the throttle lever fully aft. The airplane subsequently touched down long on the 5,000-ft runway and traveled off the end and down an embankment, coming to rest upright. Postaccident examination of the engine did not reveal any anomalies with the throttle linkage. However, the No. 3 cylinder exhaust valve was stuck in the open position. Metallurgical examination of the No. 3 cylinder revealed rough residues and patches in the valve guide, as well as valve guide material that had adhered to the exhaust valve stem. Caked residues were observed around the exhaust valve tip. Measurements of the exhaust valve guide bore’s inside diameter were all below specification for a new valve guide, and the diametral valve-to-guide clearances were also below specification at the middle and inboard end of the guide. The cylinder had been operated for about 1,072 hours since it was installed new about 3 years before the accident. Available evidence indicates that, over time, the improperly manufactured exhaust valve guide bore allowed a build-up of residual material that led to the exhaust valve becoming stuck in the open position and a partial loss of engine power.

Factual narrative

On September 23, 2024, about 1442 eastern daylight time, a Piper PA-28-161, N4298V, was substantially damaged when it was involved in an accident near LaGrange, Georgia. The flight instructor and student pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that after completing maneuvers over the local area, the student pilot performed a touch-and-go landing on runway 31 at LaGrange-Calloway Airport (LGC), LaGrange, Georgia. During the initial climb after the touch-and-go landing, about 200 to 300 ft above ground level, the engine began to run rough and the airplane stopped climbing. The flight instructor then took control of the airplane from the student pilot and made a right turn for a forced landing on runway 21. The flight instructor further stated that during the landing attempt, the engine power did not reduce all the way to idle when he pulled the throttle lever fully aft. The airplane subsequently touched down long on the 5,000-ft runway and traveled off the end and down an embankment, coming to rest upright. Examination of the wreckage revealed that the landing gear collapsed and the left wing was substantially damaged. The wreckage was retained for further examination. Additionally, an Avidyne IFD540 was recovered and forwarded to the National Transportation Safety Board (NTSB) Vehicle Recorders Laboratory, Washington, DC, for data download. The engine was further examined at a recovery facility by a representative of the engine manufacturer, under the supervision of an FAA inspector. No issues were identified with the throttle linkage. The examination revealed that the No. 3 cylinder exhaust valve was stuck in the open position; no other anomalies were noted with the airframe or engine. The No. 3 cylinder was then forwarded to the engine manufacturer for metallurgical examination under the supervision of an NTSB investigator. The metallurgical examination revealed rough residues and patches in the valve guide and valve guide material adhered to the exhaust valve stem. Caked residues were observed around the exhaust valve tip. Coked oil deposits appeared to be present in the rocker box around the exhaust valve guide and the cylinder head cooling fins around the exhaust port appeared white around the exhaust port, consistent with heat tinting. Measurements of the exhaust valve guide bore’s inside diameter were all below specification for a new valve guide, and the diametral valve-to-guide clearances were also below specification at the middle and inboard ends of the guide. As of the publication of this report, the engine manufacturer was conducting an internal investigation to address the issue. Download of the Avidyne IFD540 data revealed that no engine data had been stored. Review of maintenance records revealed that the No. 3 cylinder had been operated for about 1,072 hours since it was installed new on December 22, 2021.

Aircraft

Registration
N4298V
Reported as
Piper PA28 (161)
Category
Airplane
Serial number
28-8316059
Built
1983
Airframe hours
6,618
Engine
Lycoming O-320, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Airventures
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 24, 2024 · 45 hours before
Airport
LGC · LaGrange-Calloway Airport, runway 21, 5,000 × 100 ft, asphalt
Equipment
Stall warning system, Electronic primary flight display, 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
Flight instructor
Age
61
Injuries
Minor
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
November 29, 2023
Seat
Right
Restraint
Lap only
Flight hours
2,080 total · 1,301 in this make and model · 1,957 as pilot in command · 77 in the last 90 days · 30 in the last 30 days · 2 in the last 24 hours
Role
Student pilot
Age
53
Injuries
Minor
Certificate
Student
Seat
Left
Restraint
3-point
Flight hours
60 total · 60 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 3 knots
Visibility
10 statute miles
Lowest ceiling
6,000 ft broken
Temperature
93 °F, dew point 63 °F
Altimeter
29.94 inHg
Observed at
LGC
METAR
KLGC 231855Z AUTO 27003KT 10SM BKN060 34/17 A2994

Docket · 12

The files NTSB released with the investigation on October 22, 2025, on NTSB’s docket system: statements, records, photos and specialists’ reports. 22.1 MB in all.