LAX93LA229

NTSB accident investigation · Piper PA-28R-200 · Hesperia, CA · May 27, 1993

Accident · No injuriesLimited investigationFinal report
Date
May 26, 1993, 23:15 local (May 27, 1993, 06:15 UTC)
Place
Hesperia, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4820TPiper PA-28R-200
Weather
Visual (VMC) · Night/dark
Status
Completed · report September 15, 1994
Report
Approved by Office Director
FAA report
19930526015299A
Case key
28393

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

Fatigue failure of the exhaust valve due to inadequate maintenance and inspection.

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/malfCruise
Engine assembly,valve,exhaust - fatigueCause
Maintenance - inadequateOther maintenance personnelCause
Forced landingLanding - flare/touchdown
On ground/water encounter with terrain/waterLanding - roll
Terrain condition - ravine

Analysis

The engine sustained a total loss of power while in cruise flight. The pilot was unable to negotiate the selected airport, and the airplane collided with a ravine during the landing 1/2 mi from the runway. Engine teardown examination disclosed that the #2 exhaust valve failed in fatigue. The engine was last overhauled about 9 yrs before the accident, and had accrued about 1,443 hrs.

Factual narrative

On May 26, 1993, at 2315 hours Pacific daylight time, a Piper PA28R-200, N4820T, crashed about 1/2 mile east of Hesperia Airport, Hesperia, California. The pilot was conducting a cross country visual flight rules personal flight. The airplane, registered to and operated by the pilot, sustained substantial damage. Neither the certificated private pilot nor his passenger was injured. Visual meteorological conditions prevailed. The flight departed Apple Valley Airport, Apple Valley, California, at about 2230 hours.

The pilot reported that after leveling off at cruising altitude the engine began to "sputter, knock and then lost power." The pilot elected to land at Hesperia Airport. The airplane's altitude, however, was insufficient to negotiate the airport, and the airplane crashed west of a ravine, about 1/2 mile east of the airport.

On June 30, 1993, the engine was examined at Lynn's Aircraft Engines, Inc., El Monte Airport, El Monte, California. Mr. Charles Little, Textron Lycoming, participated in the examination. Continuity of the gear and valve train assembly was established prior to disassembly of the engine.

The disassembly examination disclosed that the number 2 cylinder exhaust valve head was partially missing. The fractured area displayed extensive beach marks which according to metallurgical data are consistent with fatigue. The corresponding cylinder head and piston dome displayed extensive foreign object damage; a piece of the exhaust valve was found embedded in the piston dome. The oil control ring was found seized in its respective land groove.

The number 3 cylinder skirt area displayed three scalloped areas had been ground out. According to the Textron Lycoming representative, that grinding of the skirt area is not an authorized repair. The nos. 1, 3, and 4 cylinder heads and piston domes displayed misfiring signatures. The number 3 oil control ring was also found seized in its respective land groove.

An unidentified red silicon material was found on several crankcase bolt holes and on the accessory case. The crankshaft gear and oil pump shaft displayed wear patterns consistent with only one side of the pump gears making contact. Light fretting signatures were found on the case half parting surface.

The connecting rods, nos. 1, 3, and 4, displayed extensive pitting on the I-Beam section and around the cap area. The number 1 connecting rod is marked as the number 6 rod. The crankshaft main bearing and the connecting rod bearings displayed light scoring signatures. The connecting rods weights were found within the manufacturer's service limits.

Carbon deposits were observed on the oil suction screen.

Both top and bottom spark plugs on the number 2 cylinder sustained extensive foreign object damage. The remaining spark plugs displayed center electrode ovaling patterns.

Both magnetos were examined at Roberts Aircraft Components, California City Airport, California City, California. Both magnetos operated normally.

The fuel servo unit and the diaphragm fuel pump contained bluish colored fuel. The fuel pump operated normally during hand operation.

Examination of the engine logbook revealed that the engine received a major overhaul on June 1, 1984. The engine total time at overhaul was 1,834 hours. At the time of the accident, the engine accrued 1,443 hours since it was overhauled and a total time of 3,277 hours.

Aircraft

Registration
N4820T
Reported as
Piper PA-28R-200
Category
Airplane
Serial number
28R-7235116
Airframe hours
6,238
Engine
Lycoming IO-360-C1C, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Steven B. & Kerry K. Madewell
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 1, 1993 · 20 hours before
Departed
APV · Apple Valley, CA
Destination
L67 · Rialto, 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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
29
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
151 total · 118 in this make and model · 114 as pilot in command · 32 in the last 90 days · 11 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
190° at 30 knots, gusting 40
Visibility
15 statute miles
Lowest ceiling
None

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 N4820T · 1

Matched to the same aircraft by N-number and date.