# NTSB ERA24LA392: Piper PA28, N4298V, LaGrange, GA, September 23, 2024

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Class 3 · Limited · Final report
- Date: September 23, 2024, 14:42 local (18:42 UTC)
- Place: LaGrange, GA
- Coordinates: 33.009151, -85.073204
- Nearby events: https://openairdocs.org/map.md?lat=33.0092&lon=-85.0732&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342)
- Highest injury: Minor injuries
- Injuries: 2 minor
- 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
- NTSB case key (mKey): 195170
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA24LA392
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/195170/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=195170
- Page: https://openairdocs.org/ntsb/ERA24LA392

## 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

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

- [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-28-161, 3 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=7102803), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md)
- [Manufacture/production: equipment manufacture](https://openairdocs.org/ntsb-findings/04013010): Organizational issues › Development · Manufacturer (probable cause); cases with it: [Piper PA-28-161, 1 case](https://openairdocs.org/ntsb-findings/04013010/cases.md?model=7102803), [All aircraft, 36 cases](https://openairdocs.org/ntsb-findings/04013010/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 (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Piper PA-28-161, 13 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7102803), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md)
- [Emergency descent: Landing area overshoot](https://openairdocs.org/ntsb-events/380); cases with it: [Piper PA-28-161, 9 cases](https://openairdocs.org/ntsb-events/380/sequence.md?model=7102803), [All aircraft, 400 cases](https://openairdocs.org/ntsb-events/380/sequence.md)
- [Landing: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Piper PA-28-161, 30 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7102803), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md)
- [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-161, 58 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102803), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## 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](https://openairdocs.org/aircraft/N4298V), registered now, S/N 28-8316059 (OpenAirDocs)
- Reported make and model: PIPER PA28 (161)
- Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs)
- Category: Airplane
- Serial number: 28-8316059
- Year built: 1983
- Airframe hours: 6618
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Flight instructor; age 61; injuries: minor; 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
- Student pilot; age 53; injuries: minor; 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 files)

The files NTSB released with the investigation on October 22, 2025, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=195170. 22.1 MB in all.

- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 10 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18910756&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf
- Flight instructor written statement (item 2, PDF, 1 page, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18910790&FileExtension=pdf&FileName=Instructor%20Written%20Statement_Redacted-Rel.pdf
- Student pilot written statement and additional information (item 3, PDF, 2 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18910980&FileExtension=pdf&FileName=Student%20Pilot%20Written%20Statement%20And%20Information_Redacted-Rel.pdf
- Witness statements (item 4, PDF, 3 pages, 700 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18911400&FileExtension=pdf&FileName=Eyewitness%20Statements%20(9-23-2024)_Redacted-Rel.pdf
- Additional information from operator (item 5, PDF, 1 page, 313 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18910617&FileExtension=pdf&FileName=Information%20From%20Operator-Rel.pdf
- Excerpts from maintenance logbooks (item 6, PDF, 14 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18911189&FileExtension=pdf&FileName=Mx%20Excerpts_Redacted-Rel.pdf
- Google earth (kmz file) - ADS-B plot of accident flight (item 7, KMZ, 230 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18910766&FileExtension=kmz&FileName=20240923_A52092_566013663-Rel.kmz
- NTSB metallurgical evaluation (item 8, PDF, 1 page, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18911058&FileExtension=pdf&FileName=Metallurgical%20Evaluation-Rel.pdf
- Investigation photographs (item 9, PDF, 12 pages, 11 photos, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18911639&FileExtension=pdf&FileName=Investigation%20Photographs-Rel.pdf
- Avidyne ifd 540 - specialist's email report (item 10, PDF, 1 page, 12.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17958031&FileExtension=pdf&FileName=ERA24LA392%20(Lagrange,%20GA)%20Avidyne%20IFD540%20Email%20Report_2-Rel.pdf
- Statement of party representatives to NTSB investigation (item 11, PDF, 9 pages, 358 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18911309&FileExtension=pdf&FileName=Party%20Form_Redacted-Rel.pdf
- Evidence control forms (item 12, PDF, 2 pages, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18911319&FileExtension=pdf&FileName=Evidence%20Control%20Forms-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.