FTW92GA111

NTSB accident investigation · Piper PA-32R-301T · Albuquerque, NM · April 9, 1992

Accident · FatalFinal report
Date
April 9, 1992, 16:20 local (23:20 UTC)
Place
Albuquerque, NM
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N8194XPiper PA-32R-301T
Weather
Visual (VMC) · Day
Status
Completed · report June 30, 1993
Report
Approved by Office Director
Case key
18380

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

Fuel line failure due to vibratory fatigue. Factors were improper maintenance, manufacturer information for fuel line not available, and the pilots' failure to follow emergency procedures.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

FireClimb - to cruise
Fuel system,line - failure,totalCause
Fuel system,line - vibrationCause
Fuel system,line - fatigueCause
Fuel system,line - not securedFactor
Maintenance,installation - improperFactor
Information unavailableManufacturerFactor
Forced landingDescent - emergency
Emergency procedure - not followedPilot in commandFactor
In flight collision with terrain/waterLanding - flare/touchdown

Analysis

The airplane sustained an in-flight fire and during the forced landing impacted the terrain nose low. According to ATC, the pilot diverted to an alternate airport after reporting smoke in the cockpit. According to witnesses, the pilot did not shut down the engine. Witnesses reported that the airplane entered a downwind pattern and impacted the terrain after overshooting the runway during the approach. Investigation revealed that the fuel line to the no. 5 cylinder had separated over time by cyclic stresses that propagated a fatigue crack. The maintenance installation of the line had been improperly routed and the line not clamped. Manufacturer information on the line routing and clamps had not been available in the service bulletins. The exhaust pipe exhibited mechanical abrasion and thermal oxidation prior to the accident although the exhaust system had undergone a recent maintenance check. A 'b' nut missing on the top spark plug for the no. 5 cylinder had been situated at a location of intense heat during the in-flight fire. Surface cracks penetrating the inside surface of the v-band coupling securing the exhaust pipe exhibited surface oxidation damage determined to be in existence for some time prior to the accident.

Aircraft

Registration
N8194X
Reported as
Piper PA-32R-301T (PA-32R-301)
Category
Airplane
Serial number
32R8029086
Airframe hours
2,986
Engine
Lycoming TIO-540-S1AD, 300 horsepower, reciprocating
Damage
Substantial damage
Fire
In-Flight
Flight
Public aircraft · Part 91
Operator
New Mexico Transportation Dept
Registered owner
New Mexico Transportation Dept
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 27, 1991 · 368 hours before
Departed
ABQ
Destination
SAF · Santa Fe, NM
Airport
4AC · Coronado, runway 3, 3,500 × 40 ft, asphalt

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
62
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
6,828 total · 1,693 in this make and model · 6,668 as pilot in command · 71 in the last 90 days · 34 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 5 knots
Visibility
60 statute miles
Lowest ceiling
None
Temperature
77 °F, dew point 18 °F
Altimeter
29.00 inHg
Observed at
ABQ, 15 nm away