# NTSB IAD05LA064: Piper PA-28-140, N55165, Dover, DE, May 14, 2005

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Limited investigation · Final report
- Date: May 13, 2005, 23:00 local (May 14, 2005, 03:00 UTC)
- Place: Dover, DE
- Coordinates: 39.20111, -75.483329
- Nearby events: https://openairdocs.org/map.md?lat=39.2011&lon=-75.4833&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Minor injuries
- Injuries: 3 minor
- Status: Completed, report April 25, 2006
- Report: Approved by Office Director
- Parties: FAA FSDO-17
- NTSB case key (mKey): 61477
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=IAD05LA064
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/61477/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=61477
- Page: https://openairdocs.org/ntsb/IAD05LA064

## Probable cause

The separated baffle which blocked the tailpipe resulting in a subsequent total loss of engine power.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power(total) - mech failure/malf, climb
  - exhaust system,baffle - separation (cause)
  - exhaust system - blocked(total)
- Forced landing, descent - emergency
- In flight collision with terrain/water, emergency landing
  - terrain condition - ground

## Analysis

On a night departure from an airport, the airplane's engine experienced a total loss of power. The pilot attempted to regain engine power without result. The pilot subsequently performed a forced landing to a field substantially damaging the airplane. No preimpact mechanical malfunctions of the engine were noted; however, examination of the exhaust system revealed that a portion of the internal baffle in the muffler assembly had separated from the surrounding structure, and was free to move around inside the muffler. Further examination of the exhaust system showed that the tailpipe was equipped with an arch shaped standoff assembly that extended from the inboard end of the tailpipe and protruded into the muffler to prevent a loose exhaust baffle from covering the inboard end of the tailpipe. Examination of the alignment holes on both the tailpipe and muffler revealed that when both holes were aligned, the standoff assembly did not protrude far enough into the muffler to keep the loose portion of the baffle from blocking the tailpipe. The manufacturer recommended that the entire exhaust system, including heat exchange shroud, muffler, muffler baffles, stacks and all exhaust connections be rigidly inspected at each 100-hour inspection and that the possibility of exhaust system failure increases with use. Additionally, it was recommended that all airplanes be fitted with a new muffler at or near the 1,000 hour period of which the muffler had been used. The airplane was manufactured in 1973 and an overhauled tail pipe was installed at 4510.77 total hours of operation. The airplane's most recent 100 hour inspection was completed on March 31, 2005. At the time of the inspection, the airplane had accrued 5574 total hours of operation. At the time of the accident, the airplane had operated 76.14 hours since its last inspection.

## Factual narrative

On May 13, 2005, about 2300 eastern daylight time, a Piper PA-28-140, N55165, was substantially damaged following a collision with terrain during the initial climb from the Chandelle Estates Airport (0N4), Dover, Delaware. The certificated commercial pilot and two passengers received minor injuries. Night visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, destined for the Lehigh Valley International Airport (ABE), Allentown, Pennsylvania, which was conducted under 14 CFR Part 91.

According to the pilot, after completing the pre-takeoff checklist, and normal engine runup, he departed runway 22 at Chandelle Estates Airport. During the initial climb he noticed a "substantial decrease" in power. He lowered the nose of the airplane to gain airspeed, and adjusted the throttle control in an attempt to regain engine power, without result. The pilot subsequently performed a forced landing to a field approximately 1/2 mile from the departure end of the runway.

Examination of the Airplane by a Federal Aviation Administration (FAA) inspector revealed that during the forced landing, the right wing had separated at the wing root, the left wing outer wing panel was wrinkled and twisted, the fuselage exhibited compression buckling in multiple locations, all three landing gear legs were broken off and the engine had been displaced approximately 10 degrees to the right and down 5 degrees.

No preimpact mechanical malfunctions of the engine were noted; however, examination of the exhaust system revealed that a portion of the internal baffle in the muffler assembly had separated from the surrounding structure, and was free to move around inside the muffler. Further examination of the exhaust system showed that the tailpipe was equipped with an arch shaped standoff assembly that extended from the inboard end of the tailpipe and protruded into the muffler.

According to the FAA inspector, the arch shaped standoff was designed to extend far enough into the muffler to prevent a loose exhaust baffle from covering the inboard end of the tailpipe. Examination of the alignment holes on both the tailpipe and muffler revealed that when both holes were aligned, the standoff assembly did not protrude far enough into the muffler to keep the loose portion of the baffle from blocking the tailpipe.

The Piper Cherokee Service Manual states, "The entire exhaust system, including heat exchange shroud, muffler, muffler baffles, stacks and all exhaust connections must be rigidly inspected at each 100-hour inspection. The possibility of exhaust system failure increases with use. It is recommended that the system be checked more carefully as the number of hours increase, therefore inspection at the 700 hour period, that the exhaust system has been in use would be more critical than ones in the 100 hour period."  It goes on to state, "Removal of the tail pipe and stacks is required for inspection of the muffler baffle. Remove or loosen all exhaust shields, carburetor and cabin heat muffs, shrouds, heat blankets, etc., as required to permit inspection of the complete system. Perform the necessary cleaning operations and inspect all external surfaces for dents, cracks and missing parts. Pay particular attention to welds, clamps. supports and support attachment lug's, slip joints. stack flanges and gaskets. Inspect internal baffle or diffusers. Any cracks, warpage or severe oxidation are cause for replacement of the muffler. Additionally, it states, " NOTE: It is recommended that all PA-28 airplanes be fitted with a new muffler at or near the 1000 hour period of which the muffler has been used."

The airplane was manufactured in 1973. According to the airplane's maintenance records, a "newly overhauled tail pipe" was installed at 4510.77 total hours of operation. The airplane's most recent 100 hour inspection was completed on March 31, 2005. At the time of the inspection, the airplane had accrued 5574 total hours of operation. At the time of the accident, the airplane had operated 76.14 hours since its last inspection.

## Aircraft

- Registration: [N55165](https://openairdocs.org/deregistered/N55165-2009-12-09), registration cancelled 2009-12-09, S/N 28-7325336, built 1973 (OpenAirDocs)
- Reported make and model: Piper PA-28-140
- Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs)
- Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 28-7325336
- Airframe hours: 5646.74
- Engines: Lycoming O-320-E3D 150 horsepower reciprocating
- Damage: Substantial damage
- Flight: Instructional, Part 91
- Operator: Ace Pilot Training Inc.
- Registered owner: Gus G. Yialamas
- Airworthiness certificate: Standard, Normal
- Last inspection: 100 hour, March 1, 2005, 76.14 hours before
- Departed: 0N4, Dover, DE
- Destination: ABE, Allentown, PA
- Airport: 0N4, Chandelle Estates Airport, runway 22, 2,533 × 772 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 23; injuries: minor; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review November 1, 2004; seat: right; flight hours: 705 total, 278 in this make and model, 646 as pilot in command, 191 in the last 90 days, 96 in the last 30 days, 6 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Night
- Wind: 180° at 8 knots
- Visibility: 7 statute miles
- Lowest ceiling: 5,000 ft overcast
- Temperature: 52 °F, dew point 39 °F
- Altimeter: 30.20 inHg
- Observed at: DOV, 5 nm away

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20050513018919A](https://openairdocs.org/incident/20050513018919A), May 13, 2005: Piper PA28140, Dover, DE, Substantial damage. (-23) On may 13, 2005, about 2200 eastern daylight time, a Piper PA-28-140 airplane, N55165, was substantially damaged during takeoff. The aircraft lost power…

## Docket (7 files)

The files NTSB released with the investigation on February 1, 2006, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=61477. 1.3 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 459 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40424993&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Interview Summaries (item 2, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40424994&FileExtension=.PDF&FileName=Interview%20Summaries-Redacted.PDF
- Excerpts From Maintenance Records (item 3, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40424995&FileExtension=.PDF&FileName=Excerpts%20From%20Maintenance%20Records-Redacted.PDF
- Excerpt From Piper Cherokee Service Manual (item 4, .PDF, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244219&FileExtension=.PDF&FileName=Excerpt%20From%20Piper%20Cherokee%20Service%20Manual-Master.PDF
- Photograph 1 - Main Wreckage (item 5, .PDF, 486 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244220&FileExtension=.PDF&FileName=Photograph%201%20-%20Main%20Wreckage-Master.PDF
- Photograph 2 - Separated Internal Baffle (item 6, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244236&FileExtension=.PDF&FileName=Photograph%202%20-%20Separated%20Internal%20Baffle-Master.PDF
- Photograph 3 - Tailpipe Arched Standoff and Alignment Hole (item 7, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40244237&FileExtension=.PDF&FileName=Photograph%203%20-%20Tailpipe%20Arched%20Standoff%20and%20Alignment%20Hole-Master.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.

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