FTW98LA350

NTSB accident investigation · Piper PA-31-350 · Alamosa, CO · August 8, 1998

Accident · No injuriesLimited investigationFinal report
Date
August 8, 1998, 11:50 local (17:50 UTC)
Place
Alamosa, CO
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N27196Piper PA-31-350
Weather
Visual (VMC) · Day
Status
Completed · report February 22, 2001
Report
Approved by Office Director
FAA report
19980808037729A
Case key
43671

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

Improper major overhaul of the engine by the overhaul facility. Factors were failure of the V-band clamp, the melting of the baffle and manifold clamp, and the pilot not being able to extend the landing gear.

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(total) - mech failure/malfApproach
1 engine
Exhaust system,turbochargerFactor
Exhaust system,clamp - failure,totalFactor
Exhaust system,baffle - meltedFactor
Exhaust system,manifold/pipe - meltedFactor
Maintenance,overhaul,major - improperOther maintenance personnel
Forced landingDescent - emergency
Engine shutdown - intentionalPilot in command
Propeller feathering - performedPilot in command
Gear extension - not possiblePilot in commandFactor
In flight collision with terrain/waterLanding - roll
Terrain condition - open field

Analysis

The airplane was being ferried to its home base after both engine had received major overhauls. As the airplane approached Alamosa, the left engine lost power. Unable to restart the engine, the pilot feathered the propeller. The landing gear would only extend partially. The airplane would not maintain flying speed nor altitude and the pilot elected to make a forced landing in a cow pasture. Examination of the engine disclosed a broken coupling bolt on the right side of the turbocharger, preventing the V-band clamp from completely securing the exhaust pipe to the turbocharger, permitting hot exhaust gases to escape into the engine compartment. The turbocharger transition baffle was found partially melted and the manifold pressure line was burnt through and separated, allowing the mixture to enrichen and flood the engine. Textron Lycoming Service Bulletin 240P requires all V-band couplings and gaskets to be replaced when an engine is overhauled. The failed V-band coupling was found to be rusted and discolored, suggesting it had not been replaced. Additionally, the failed manifold pressure line used was made of rubber instead of flex stainless steel line.

Factual narrative

On August 8, 1998, approximately 1150 mountain daylight time, a Piper PA-31-350, N27196, owned by Capitol Express Airlines, Inc., and operated by Air Bridge, Inc., was substantially damaged during a forced landing at Alamosa, Colorado. The airline transport-rated pilot, the sole occupant aboard, was not injured. Visual meteorological conditions prevailed, and a VFR flight plan had been filed for the ferry flight being conducted under Title 14 CFR Part 91. The flight originated at Kansas City, Missouri, at 0733 central daylight time.

Both engines had recently been overhauled by T.W. Smith Engine Co., Inc., in Cincinatti, Ohio, and the airplane was being ferried to its home base at North Las Vegas, Nevada. The airplane was then to be placed on the operating certificate of a new carrier, Air Bridge, Inc.

According to the pilot's accident report, the left engine lost power as the airplane approached Alamosa. Unable to restart the engine, he feathered the propeller. When he attempted to lower the landing gear, it would only partially extend. He attempted but was unable to lower the landing gear manually. This necessitated a go around. The airplane would not maintain flying speed nor altitude due to the drag from the partially extended landing gear. The pilot decided to make a forced landing in a cow pasture about one mile south of the airport. During the ensuing landing, the airplane sustained substantial damage.

On August 20, 1998, the left engine, a Lycoming TIO-540-J2BD (s/n L-4489-61A), was examined and functionally tested at the facilities of Mountain View Aeromotive, Alamosa, Colorado. In attendance were representatives of AIG Aviation and T.W. Smith Engine Co., Inc. The Federal Aviation Administration, Textron Lycoming Engines, and Hartzell Propellers chose not to participate.

According to reports submitted by Mr. Ronald L. Ecord of Mountain View Aeromotive and Mr. Myron Carlson of AIG Aviation, a broken coupling bolt was noted on the right side of the turbocharger, preventing the V-band clamp from completely securing the exhaust pipe to the turbocharger. This would allow extremely hot exhaust gases to escape into the engine compartment. The turbocharger transition baffle was found to be partially melted and the manifold pressure line leading to the differential pressure controller was burnt through and was separated. This condition would allow the mixture to enrichen and the engine to flood. Its attachment fitting was also partially melted.

Without changing the damaged parts, the engine was placed in a test cell and started. Maximum manifold pressure attained was 29 inches and the engine ran rich at all power settings. To simulate the pilot's action, the mixture was placed in the full rich position and the throttle was closed. The engine quit.

The damaged manifold pressure line was replaced with a new one and the engine restarted. Maximum manifold pressure attained was 42 inches. The mixture was placed in the full rich position. When the throttle was closed, the engine did not quit but continued to operate at idle power.

According to Textron Lycoming Service Bulletin 240P, dated May 4, 1998, all V-band couplings and gaskets are to be replaced when an engine is overhauled. The failed V-band coupling was found to be rusted and discolored. Its condition suggests it had not been replaced. Additionally, the failed manifold pressure line was made of rubber instead of a flex stainless steel line.

Aircraft

Registration
N27196
Reported as
Piper PA-31-350
Category
Airplane
Serial number
77-52095
Airframe hours
12,931
Engine
Lycoming TIO-540-J2BD, 350 horsepower, reciprocating
Damage
Substantial damage
Flight
Ferry · Part 91
Operator
Air Bridge, Inc.
Registered owner
Capitol Express Airlines, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 3, 1998 · 16 hours before
Departed
MKC · Kansas City, MO
Destination
ALS · CO

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
52
Certificates
Airline transport, Commercial
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
4,741 total · 522 in this make and model · 4,420 as pilot in command · 216 in the last 90 days · 88 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
240° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 43 °F
Altimeter
30.00 inHg
Observed at
ALS, 1 nm away

Docket · 8

The files NTSB released with the investigation on September 28, 1998, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.1 MB in all.

FAA reports on this event · 1

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