LAX97LA163

NTSB accident investigation · Piper PA-28R-201T · Tucson, AZ · April 18, 1997

Accident · No injuriesLimited investigationFinal report
Date
April 18, 1997, 13:06 local (20:06 UTC)
Place
Tucson, AZ
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N2847FPiper PA-28R-201T
Weather
Visual (VMC) · Day
Status
Completed · report May 4, 1998
Report
Approved by Office Director
FAA report
19970418006119A
Case key
29775

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 partial blockage of the No. 2 cylinder injection line/nozzle by a transient contaminant, which induced an excessively lean mixture in that cylinder, and the subsequent overheating of the cylinder and intake valve. The engine power loss was due to the open intake valve allowing hot exhaust gasses into the induction system. The contamination was due to inadequate installation/inspection procedures used by the operator's maintenance organization when the fuel system was reinstalled on the engine following the overhaul.

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/malfTakeoff - initial climb
Fuel system,injector - blocked(partial)Cause
Maintenance,installation - inadequateCompany maintenance personnelCause
Fuel system,injector - output lowCause
Engine assembly,valve,intake - overtemperatureCause
Engine assembly,valve,intake - jammedCause
Forced landingEmergency landing after takeoff
On ground/water collision with objectLanding - roll
Object - tree(s)

Analysis

At 300 feet agl in the takeoff initial climb the engine ran roughly for a moment, then smoothed out for a short time at a low power output. The pilot stated that the engine power was insufficient for flight, and, he did not feel that he had sufficient altitude or vehicle energy to return to the runway. The pilot therefore elected to land on a dirt road. The right wing contacted trees during the landing rollout. An engine overhaul was completed on April 3, 1997, and it was reinstalled on the airframe on April 17th, 2 hours prior to the accident. The overhaul facility performed work on only the core engine. The operator's maintenance facility reinstalled all accessories, including all fuel system components, on the engine prior to installing it on the airframe. External visual examination of the engine noted blistered, missing, and discolored paint on the No. 2 cylinder, which had no compression. No valve lash was observed at the No. 2 cylinder intake valve, and air leakage was noted from that area. Exhaust gas residue was noted in all intake tubes during their removal from the engine. The No. 2 cylinder bottom spark plug electrode was damaged, with deposits of what appeared to be molten metal particles. The plugs for cylinders 1, 3, and 4 exhibited sooting. All fuel injection nozzles, including the No. 2 cylinder, were unobstructed. Bench flow tests confirmed normal postaccident flows for the distributor, nozzles, and lines. The No. 2 cylinder was removed from the engine. The piston and combustion chamber were burned. The intake valve stem and back face were burned, and the head was distorted into a tulip configuration. The valve length was stretched. No other internal abnormalities were noted with the engine.

Factual narrative

On April 18, 1997, at 1306 mountain standard time, a Piper PA-28R-201T, N2847F, collided with trees during a forced landing near the Ryan airport, Tucson, Arizona. The forced landing was precipitated by a loss of engine power during the takeoff initial climb from runway 6R at Ryan airport. The aircraft was operated by Chandler Air Service of Chandler, Arizona, and was rented by the pilot for the personal cross-country flight. Visual meteorological conditions prevailed at the time and no flight plan was filed for the operation. The aircraft sustained substantial damage. The certificated commercial pilot and his one passenger were not injured. The flight was originating as a return to Chandler.

In his written statement, the pilot reported that he had initial difficulty starting the engine, but following use of a ground power unit the engine started. All ground taxi and run-up operations appeared to be normal. At 300 feet agl in the takeoff initial climb the engine ran roughly for a moment, then smoothed out for a short time at what the pilot believed was a lower power output. The pilot stated that the engine power was insufficient for flight, and, he did not feel that he had sufficient altitude or vehicle energy to return to the runway. The pilot therefore elected to land on a dirt road. The right wing contacted trees during the landing rollout.

An initial review of the maintenance records disclosed that the Lycoming IO-360-C1C6 engine, serial number L-18733-51A, completed an overhaul on April 3, 1997, and was reinstalled on the airframe on April 17, 2 hours prior to the accident. The records established that the overhaul facility performed work on only the core engine. The operator's maintenance facility reinstalled all accessories, including all fuel system components, on the engine prior to installing it on the airframe. Pertinent portions of the maintenance records are attached.

Following recovery of the aircraft to a storage facility in Phoenix, the engine was examined by the Safety Board with the assistance of a technical representative from Textron Lycoming engines. External visual examination of the engine noted blistered, missing, and discolored paint on the No. 2 cylinder. Rotation of the crankshaft verified accessory gear and valve train continuity, with compression noted in all but the No. 2 cylinder. Magneto to engine timing was found to be within published Lycoming limits. No valve lash was observed at the No. 2 cylinder intake valve, and air leakage was noted from that area. No dry tappet clearance was noted on this valve.

Exhaust gas residue was noted in all intake tubes during their removal from the engine.

The No. 2 cylinder bottom spark plug electrode was damaged, with deposits of what appeared to be molten metal particles. The plugs for cylinders 1, 3, and 4 exhibited sooting. All fuel injection nozzles, including the No. 2 cylinder, were unobstructed. The fuel injection line from the distributor to the No. 2 nozzle was observed to be bent at the nozzle end beyond the minimum bend radius specified by Lycoming, and a slight crimp was noted in the bend area.

The No. 2 cylinder was removed from the engine. The piston and combustion chamber were burned. The intake valve stem and back face were burned, and the head was distorted into a tulip configuration. The valve length was stretched.

The fuel nozzle and associated line from the No. 2 cylinder were taken to a Bendix authorized repair station for a flow test in accordance with the procedures specified in the appropriate Bendix overhaul/repair manual. The components flowed with specified limits. The fuel distributor was subsequently flow tested and functioned within specifications.

Aircraft

Registration
N2847F
Reported as
Piper PA-28R-201T (PA-28R-201)
Category
Airplane
Serial number
28-7918172
Airframe hours
5,712
Engine
Lycoming IO-360-C1C6, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Chandler Air Service
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · April 17, 1997 · 2 hours before
Departed
RYN
Destination
CHD · Chandler, 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
25
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
1,129 total · 36 in this make and model · 946 as pilot in command · 356 in the last 90 days · 109 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
50° at 6 knots
Visibility
30 statute miles
Lowest ceiling
None
Temperature
81 °F

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.