LAX96LA023

NTSB accident investigation · Great Lakes 2T-1A-2 · Chandler, AZ · October 26, 1995

Accident · No injuriesLimited investigationFinal report
Date
October 26, 1995, 16:10 local (23:10 UTC)
Place
Chandler, AZ
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N3808FGreat Lakes 2T-1A-2
Weather
Visual (VMC) · Day
Status
Completed · report April 1, 1996
Report
Approved by Office Director
FAA report
19951026034639A
Case key
29319

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

the improper installation of an intake manifold tube assembly during engine overhaul which permitted leakage into the induction system resulting in detonation and piston failure in the associated cylinder.

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(partial) - mech failure/malfManeuvering
Induction air control,intake manifold - leakCause
Maintenance,overhaul - improperCompany maintenance personnelCause
Misc,engine pre-ignition and/or detonationCause
Engine assembly,piston - failureCause
Forced landingEmergency descent/landing
On ground/water encounter with terrain/waterLanding - roll
Terrain condition - ditch
Nose overLanding - roll

Analysis

The pilot elected to make an off-airport landing due to a rough engine, oil on the windshield, and a radio report that his aircraft was trailing smoke. During the rollout on a dirt road, the aircraft struck a ditch and nosed over. Examination of the engine revealed that an intake manifold seal was leaking at the attachment to the #4 cylinder, and there was a burned hole in the #4 piston. The propeller shaft seal had been displaced forward onto the engine propeller shaft, and the engine oil supply had been vented overboard through the engine breather and around the propeller shaft. The engine had been overhauled 11 hours prior to the accident.

Factual narrative

On October 26, 1995, at 1610 hours mountain standard time, a Great Lakes 2T-1A-2, N3808F, nosed over while making a forced landing 4.5 miles southeast of Chandler Airport, Chandler, Arizona. The aircraft sustained substantial damage and the commercial pilot was not injured. The aircraft was operated by Chandler Air Service, Inc., and was rented by the pilot for a personal flight when the accident occurred. The local area flight originated from Chandler Airport at 1545. Visual meteorological conditions prevailed at the time and no flight plan had been filed.

The pilot reported that the purpose of the flight was to practice an aerobatic sequence three or four times and return to Chandler. However, at completion of the first sequence he felt an abnormal vibration in the engine and terminated his practice. The engine rpm was 200 rpm low and could not be restored with the propeller control, and within a minute engine oil began to appear on the windshield. He turned toward Chandler when the pilot of a nearby aircraft radioed that he was trailing smoke. The pilot identified a suitable dirt road and decided to make a precautionary off-airport landing. During the landing rollout, the aircraft struck a ditch and nosed over.

Examination of the aircraft revealed that the engine oil supply had vented overboard through the engine crankcase breather and the propeller shaft. There was engine oil on the exterior of the aircraft aft of the breather tube, and on the exterior of the engine aft of the propeller shaft. The propeller shaft seal was displaced from its normal position and was positioned onto the propeller shaft.

The engine had been overhauled by the operator 11 hours prior to the accident. Disassembly of the engine by the operator following the accident revealed that the intake manifold tube flange and flange gasket (Lycoming part numbers 70485 and 71973) on the number four cylinder were leaking due to misalignment. A hole had burned through the number four piston. The hole was located in the perimeter of the piston around the rings and went through to the crankcase side of the piston in vicinity of the wrist pin.

Aircraft

Registration
N3808F
Reported as
Great Lakes 2T-1A-2
Category
Airplane
Serial number
0776
Airframe hours
1,559
Engine
Lycoming AEIO-360-B1G6, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Chandler Air Service, Inc.
Airworthiness certificate
Standard, Aerobatic
Last inspection
Annual · October 22, 1995 · 11 hours before
Departed
CHD · AZ

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
35
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Rear
Flight hours
3,280 total · 280 in this make and model · 3,050 as pilot in command · 198 in the last 90 days · 86 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 4 knots
Visibility
30 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 25 °F
Altimeter
29.00 inHg
Observed at
IWA, 10 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.

Other investigations on N3808F · 1

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