- Date
- January 11, 2003, 10:23 local (18:23 UTC)
- Place
- Westlake Villag, CA
- Injuries
- 2 serious
- Damage
- Destroyed
- Phase of flight
- Enroute
- Aircraft
- N56484Piper PA-34-200
- Weather
- Visual (VMC) · Day
- Status
- Completed · report June 8, 2005
- Report
- Approved by Office Director
- Parties
- Textron Lycoming, New Piper Aircraft Company, Federal Aviation Administration, Hartzell Propeller Co.
- FAA report
- 20030111000509A
- Case key
- 56323
From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.
On this page
Probable cause
a fatigue crack in the propeller hub due to the inadequate design location of the grease fitting and the chamfering process.
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.
Analysis
The airplane collided with ground obstacles during a forced landing when the pilots could not maintain altitude after one propeller blade and part of the propeller hub from the right engine separated in flight. The CFI and the student practiced two simulated engine-out maneuvers. The CFI was reaching for the mixture control for a third simulation when he heard a loud bang. The airplane yawed violently to the right and began to lose altitude. The CFI turned toward his home field, but was having difficulty maintaining altitude. He decided that he would not be able to make it to the airport, and would have to make an off field landing. He landed in the only clear spot that he could see, which was a cemetery. The airplane collided with monuments and a wood chip pile before coming to rest next to a mausoleum. The right propeller hub fractured and separated. Investigators did not recover one blade and the corresponding part of the hub. The hub fractured as a result of fatigue cracking emanating from one of the grease-fitting holes. The fatigue cracking originated in the area of the grease-fitting threads closest to the interior surface of the hub, at the intersection between the grease-fitting hole and the chamfer. No material or manufacturing defect was found that could be identified as the source of the fatigue cracking. The fatigue cracking originated just outside the thread remnants of the grease fitting hole that were plastically deformed during a chamfering process. The grease fitting was located in a region where the wall of the hub was approximately at its thinnest, and where there was a slight change in the profile along the axis of the propeller. These geometrical factors would have led to high stresses at the edges of the hole. Chamfers were retrofitted to the grease-fitting holes by the manufacturer at both the interior and exterior surfaces of the hub in response to fatigue fractures that occurred in three-bladed propellers. This accident was the first occurrence of fatigue emanating from a grease-fitting hole for a two-bladed propeller. The chamfering was apparently introduced in an effort to smooth the stress distribution around the grease-fitting holes. The chamfer at the interior surface should have removed the stress concentration associated with the change in wall profile, but would also have decreased the amount of material in the wall, leading to higher stresses overall. The stress concentration associated with the grease-fitting hole and the chamfer, coupled with the location in a position where the hub wall was very thin, were likely sufficient to initiate fatigue cracking in this case. In more recently manufactured hubs, the grease-fitting holes have been relocated to positions where the hub wall is much thicker.
Factual narrative
History of flight
On January 11, 2003, about 1100 Pacific standard time, a Piper PA-34-200, N56484, made a forced landing in Westlake Village, California, following a loss of power in the right engine. The Aero Club was operating the airplane under the provisions of 14 CFR Part 91. The certified flight instructor (CFI) and the private pilot undergoing instruction (PUI) sustained serious injuries; the airplane was destroyed. The local instructional flight departed Van Nuys, California, about 0945. Visual meteorological conditions prevailed, and no flight plan had been filed.
The Federal Aviation Administration (FAA) accident coordinator interviewed the pilots. The CFI said that start, taxi, run up, and takeoff were uneventful. The lesson plan called for practice simulated engine-out maneuvers. The CFI said that he simulated engine loss of power by retarding the mixture control. Once the student identified the loss of power, the CFI simulated zero-thrust by setting the manifold pressure to 23 inches of Mercury, and the engine to 2,300 revolutions per minute (rpm). The PUI completed two simulated loss of power events.
The CFI said that he was reaching for the mixture control for a third simulation when he heard a loud bang. The airplane yawed violently to the right and began to lose altitude. The CFI looked out of the right window at the right engine. He did not recall seeing a propeller either stopped or rotating. He was not sure that the engine was there. The PUI informed the CFI that he was unable to maintain control, and told the CFI to take the controls.
The CFI turned toward his home field, but he was having difficulty maintaining altitude. He decided that he would not be able to make it to the airport, and would have to make an off field landing. He landed in the only clear spot that he could see, which was a cemetery. The airplane collided with monuments and a wood chip pile before coming to rest next to a mausoleum.
Personnel information
A review of FAA airman records revealed that the CFI held a commercial pilot certificate with airplane single engine and multiengine land ratings and an instrument airplane rating. The pilot held a certified flight instructor certificate with ratings for airplane single engine and multiengine land and instrument airplane.
The CFI held a second-class medical certificate issued on August 30, 2003. It had the limitations that the pilot must have glasses available for near vision.
No personal flight records were available for the CFI. The National Transportation Safety Board investigator-in-charge (IIC) obtained the aeronautical experience listed in this report from a review of the FAA airman medical records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. These records indicated a total time of 3,500 hours.
A review of FAA airman records revealed that the PUI held a private pilot certificate with an airplane single engine land rating. The PUI held a second-class medical certificate issued on June 22, 2001. It had no limitations or waivers. A review of the PUI's logbooks indicated an estimated total flight time of 145 hours. He had an estimated 6 hours of dual flight instruction in this make and model.
Aircraft information
The airplane was a Piper PA-34-200, serial number 34-7350338. The logbooks contained an entry for an annual inspection dated July 26, 2002. The left tachometer read 257.0 at the last inspection; the right tachometer read 156.6 at the last inspection. The left tachometer read 513.4 at the accident scene; the right tachometer read 411.3 at the accident scene.
The left engine was a Textron Lycoming IO-360-C1E6 engine, serial number L20922-51A. Total time on the engine was approximately 6,740 hours since a factory overhaul.
The right engine was a Textron Lycoming LIO-360-C1E6 engine, serial number RL-1115-67A. Total time on the engine was approximately 6,400 hours since a factory remanufacture.
The FAA accident coordinator obtained records, which indicated that Sky Trails at Van Nuys fueled the airplane with 51.9 gallons of 100 LL aviation fuel at 0935 on the morning of the accident. The coordinator interviewed the refueling operator who said that he filled the tanks.
Tests and research
The IIC, the FAA accident coordinator, and investigators from Piper, Textron Lycoming, and Hartzell Propellers examined the wreckage at Aircraft Recovery Service, Littlerock, California, on January 15, 2003. The left engine separated from the airplane during the collision sequence. Retrievers cut wires and cables to remove the right engine.
Left engine
Investigators slung the left engine from a hoist, and removed the top spark plugs. All spark plugs were clean with no mechanical deformation. The spark plug electrodes for all cylinders were gray in color, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart.
A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder head.
Investigators rotated the engine manually, but encountered mechanical damage and it bound after approximately 30 degrees of rotation.
Investigators manually rotated the magnetos, and both magnetos produced spark at all posts.
The fuel injector screen contained a fluid that smelled like aviation gasoline. The fuel manifold lines and nozzles were unobstructed.
The oil filter and the oil suction screen contained shiny debris that was not attracted to a magnet.
The No. 1 and No. 2 main bearings were unremarkable. The main bearing for the No. 3 journal did not have a tang and had a smooth polished appearance. It exhibited rotational scoring on the outer surface where it seated in the bearing saddle. The bearing had pits and was delaminating with areas that were missing material. The main bearing for journal No. 4 had pits.
Left Propeller
The left propeller was a Hartzell model HC-C2YK-2CGUF, serial number AU1440. Both propeller blades bent aft and exhibited trailing edge gouges. Both tips curled aft, and toward the low pitch position.
The Hartzell representative examined the left propeller. He determined that the left propeller was rotating, and not feathered at the time of impact. He could not determine the amount of power. He noted no discrepancies that would have precluded normal operation. He did not inspect the propeller vibration dampers.
Right engine
Investigators slung the right engine from a hoist, and removed the top spark plugs. All spark plugs were clean with no mechanical deformation. The spark plug electrodes for cylinders No. 1 and No. 3 were gray in color, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart. The spark plugs for cylinders No. 2 and No. 4 were oily. The engine lay on its left side during recovery.
A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder head.
Investigators manually rotated the engine using a tool in an accessory drive socket. The crankshaft rotated freely, and the valves moved approximately the same amount of lift in firing order. The vacuum pump drive gear remained unbroken, and the vacuum pump turned freely. The fuel pump plunger moved up and down, and the gears in the accessory case turned freely. Investigators obtained thumb compression on all cylinders in firing order.
The fuel pump's rubber diaphragm was unbroken and investigators blew air through the lines. The plunger in the fuel distribution valve moved freely, the rubber diaphragm was unbroken, and investigators did not observe any contamination. The fuel nozzles were open, and the screens were clean.
The right magneto sustained mechanical damage, and investigators did not test it. Investigators manually rotated the left magneto and obtained spark at all posts.
T
Aircraft
- Registration
- N56484
- Reported as
- Piper PA-34-200
- Category
- Airplane
- Serial number
- 34-7350338
- Engines
- Lycoming LIO-360-C1E6, 200 horsepower, reciprocatingLycoming IO-360-C1E6, 200 horsepower, reciprocating
- Damage
- Destroyed
- Flight
- Instructional · Part 91
- Operator
- The Aero Club
- Registered owner
- Roxy Corporation
- Airworthiness certificate
- Standard, Normal
- Last inspection
- 100 hour · November 29, 2002 · 256 hours before
- Departed
- VNY · Van Nuys, CA
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 · 2
As NTSB recorded them. NTSB leaves out names.
- Role
- Flight instructor
- Age
- 51
- Injuries
- Serious
- Certificates
- Flight instructor, Commercial
- Airplane ratings
- Single-engine land, Multi-engine land
- Instrument ratings
- Airplane
- Medical
- Class 2, Valid Medical--w/ waivers/lim
- Seat
- Right
- Flight hours
- 3,500 total
- Role
- Student pilot
- Age
- 45
- Injuries
- Serious
- Certificate
- Private
- Airplane ratings
- Single-engine land
- Medical
- Class 2, Valid Medical--no waivers/lim.
- Seat
- Left
- Flight hours
- 145 total · 6 in this make and model · 80 as pilot in command · 9 in the last 90 days · 7 in the last 30 days
Weather
- Conditions
- Visual (VMC) · Day
- Visibility
- 6 statute miles
- Lowest ceiling
- None
- Temperature
- 52 °F, dew point 46 °F
- Altimeter
- 30.17 inHg
- Observed at
- VNY, 20 nm away
Docket · 13
The files NTSB released with the investigation on April 6, 2005, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.2 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.
Other investigations on N56484 · 1
Matched to the same aircraft by N-number and date.