# NTSB LAX93LA229: Piper PA-28R-200, N4820T, Hesperia, CA, May 27, 1993 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: May 26, 1993, 23:15 local (May 27, 1993, 06:15 UTC) - Place: Hesperia, CA - Coordinates: 34.360576, -117.319534 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.3606&lon=-117.3195&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report September 15, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 28393 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX93LA229 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28393/pdf - Page: https://openairdocs.org/ntsb/LAX93LA229 ## Probable cause FATIGUE FAILURE OF THE EXHAUST VALVE DUE TO INADEQUATE MAINTENANCE AND INSPECTION. ## 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, cruise - engine assembly,valve,exhaust - fatigue (cause) - maintenance - inadequate, other maintenance personnel (cause) - Forced landing, landing - flare/touchdown - On ground/water encounter with terrain/water, landing - 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](https://openairdocs.org/deregistered/N4820T-2013-04-18), registration cancelled 2013-04-18, S/N 28R-7235116, built 1972 (OpenAirDocs) - Reported make and model: PIPER PA-28R-200 - Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7235116 - Airframe hours: 6238 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 29; 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 (OpenAirDocs). - [Accident 19930526015299A](https://openairdocs.org/incident/19930526015299A), May 26, 1993: Piper PA28R200, Hesperia, CA, Substantial damage. Engine knock power loss tried for L26 but crashed in ravine. NR2 cylinder swallowed a valve. Improper overhaul. ## Other investigations on N4820T (1) 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. - [NTSB LAX84LA370](https://openairdocs.org/ntsb/LAX84LA370), Jun 26, 1984: Piper PA-28R-200 (N4820T), Gila Bend, AZ, substantial damage 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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.