FTW96LA343

NTSB accident investigation · Piper PA-28-180 · Midlothian, TX · August 9, 1996

Accident · Minor injuriesLimited investigationFinal report
Date
August 9, 1996, 08:00 local (13:00 UTC)
Place
Midlothian, TX
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N2559RPiper PA-28-180
Weather
Visual (VMC) · Day
Status
Completed · report April 15, 1998
Report
Approved by Office Director
FAA report
19960809022729A
Case key
19941

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

maintenance personnel's improper engine overhaul procedures resulting in the installation of the rocker arms in reversed positions, which led to improper lubrication and binding of the exhaust valves. A related factor was the lack of suitable terrain for the forced landing.

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.

Loss of engine power(partial) - mech failure/malfTakeoff - initial climb
Engine assembly,rocker arm/tappet - reversedCause
Maintenance,overhaul - improperOther maintenance personnelCause
Lubricating system - inadequateCause
Engine assembly,valve,exhaust - binding(mechanical)Cause
Ignition system,magneto - assembly
Maintenance,overhaul - improperOther maintenance personnel
Ignition system,magneto - timing improper
Forced landingEmergency descent/landing
On ground/water encounter with terrain/waterEmergency landing
Terrain condition - none suitableFactor
Terrain condition - soft

Analysis

The pilot reported that during the takeoff initial climb, there was an engine vibration and a partial loss of power. A forced landing was made in a soft field, and structural damage occurred to the landing gear, propeller, firewall, engine mounts, and the left wing. During an engine test run at full power, FAA inspectors observed an engine power drop of 200 RPM; however, they were not able to duplicate the engine vibrations. Magneto timing was at 27 degrees BTDC, and a carbon brush was missing from the right magneto. The specification for timing was 25 degrees BTDC. The rocker arms had been installed in reverse positions on all four cylinders, and the FAA inspector reported that 'the exhaust valve was not receiving adequate lubrication.' Physical evidence on the exhaust valve rotator caps indicated binding of the exhaust valves. Time in service since a major engine overhaul and magneto overhaul was 170 hours. The pilot reported that before this accident 'there had not been any previous indications of engine problems since the engine overhaul.'

Factual narrative

On August 9, 1996, at 0800 central daylight time, a Piper PA-28-180, N2559R, registered to and operated by a private owner as a Title 14 CFR Part 91 flight, sustained substantial damage during the forced landing following a loss of engine power near Midlothian, Texas. The private pilot was not injured and the passenger received minor injuries. Visual meteorological conditions prevailed for the planned personal cross country flight to Angel Fire, New Mexico. A flight plan was not filed. The accident occurred at the flight origination airport.

During telephone interviews, conducted by the investigator-in-charge, the pilot reported that about 1/4 mile north of the departure end of runway 35 and 200 feet AGL, an engine vibration and a partial loss of power occurred. During a 180 degree turn toward the airport the airplane lost altitude and the landing was made to a soft field. Structural damage occurred to the landing gear, propeller, firewall, engine mounts, and the left wing. The pilot stated that the engine had 170 hours since the overhaul. The pilot further stated that prior to this accident "there had not been any previous indications of engine problems since the engine overhaul."

In October 1996, the airplane was examined under the oversight of the FAA inspectors. During an engine test run at full power, the inspectors observed an engine power drop of 200 RPM; however, they were not able to duplicate the engine vibrations that had been reported by the pilot. During an examination of the magnetos, the magneto timing was found to be 27 degrees before top dead center (BTDC). According to the FAA inspector, 25 degrees is the normal timing for these magnetos. The carbon brush was missing from the right magneto. Further inspection revealed that the rocker arms had been installed in reverse positions on all four cylinders. One FAA inspector stated that "the exhaust valve was not receiving adequate lubrication." The other FAA inspector stated that "an indication of inadequate lubrication on the exhaust valve would be excessive and premature wear in the valve guides, which in turn results in valve sticking and excessive and severe vibration of the engine." An FAA certificated mechanic, who examined the engine, stated that the "wear patterns on the exhaust valve rotator caps indicated that the exhaust valves had been binding."

A review of the maintenance records by the FAA inspectors and the investigator-in-charge revealed that the airplane was returned to service on December 4, 1994, following a major engine overhaul. Overhauled magnetos were installed at the time of the engine overhaul. On January 21, 1996, the airplane was returned to service following a 100 hour inspection at which time the mechanic entry stated in part: "checked mag[neto] timing to eng[ine], ops ck [operation check] good."

Aircraft

Registration
N2559R
Reported as
Piper PA-28-180
Category
Airplane
Serial number
28-5648
Airframe hours
3,504
Engine
Lycoming O-360-A4A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
James L. Bowling
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 21, 1996 · 51 hours before
Destination
AXX · Angel Fire, NM
Airport
T2S6 · Eagles Nest, runway 35, 3,200 × 36 ft, concrete

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
51
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
248 total · 143 in this make and model · 248 as pilot in command · 15 in the last 90 days · 9 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
6 statute miles
Temperature
82 °F

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.