MIA02LA108

NTSB accident investigation · Piper PA-32R-301 · Meridian, MS · June 7, 2002

Accident · Serious injuriesLimited investigationFinal report
Date
June 7, 2002, 13:48 local (18:48 UTC)
Place
Meridian, MS
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N697MAPiper PA-32R-301
Weather
Visual (VMC) · Day
Status
Completed · report June 25, 2003
Report
Approved by Office Director
Parties
FAA, Piper Aircraft, Lycoming Engines
FAA report
20020607013789A
Case key
54868

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

inadequate quality control of the manufacturing processes of the crankshaft gear bolt, resulting in failure of the gear bolt, due to hydrogen embrittlement, a total loss of engine power, and damage to the airplane during the subsequent forced landing.

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/malfMissed approach (ifr)
Inadequate quality controlManufacturerCause
Engine assembly,other - cracked
Engine assembly,other - failure,total
Forced landingEmergency descent/landing
In flight collision with objectEmergency descent/landing
Object - tree(s)

Analysis

The pilot had been airborne for about 45 minutes practicing turns and instrument approaches in VFR condition. He had completed a practice instrument approach to runway 1, was following the published missed approach, and the flight had attained an altitude of about 500 to 600 feet when he reported that he heard a "...loud pop, and the engine quit immediately...[without] warning of the impending engine stoppage." He declared an emergency, was cleared to land, turned left onto a short base leg to runway 1, could not maintain altitude, and he could not make it to the runway. The pilot elected to land in a field, and impacted with trees short of the runway threshold. An engine disassembly revealed that the engine failure was due a broken crankshaft gear bolt, and the separation of the crankshaft gear from the rear of the crankshaft. A laboratory examination of the failed crankshaft gear bolt, revealed that crankshaft bolt part number STD-2209, had failed due to hydrogen embrittlement. The NTSB Materials Laboratory's analysis found that the preponderance of evidence and reference information indicated that the manufacturing cycle (plating/bake delay/bake itself) was the most likely source of hydrogen embrittlement.

Factual narrative

On June 7, 2002, about 1348 central daylight time, a Piper PA-32R-301, N697MA, registered to a private individual, impacted with the ground during a forced landing near Key Field Airport, Meridian, Mississippi. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 local personal flight. The airplane was substantially damaged. The private-rated pilot reported serious injuries. The flight had originated from the same airport about 1300.

The flight had been airborne for about 45 minutes, while the pilot practiced turns and instrument approaches in VFR conditions. He had completed a practice instrument approach to runway 1, was following the published missed approach, and the flight had attained an altitude of about 500 to 600 feet, when the pilot reported, that he "...heard a loud pop, and the engine quit immediately. There was no warning of the impending engine stoppage." He declared an emergency, was cleared to land, turned left onto a short base leg to runway 1, could not maintain altitude, and he could not make it to the runway. The pilot elected to land in a field, and impacted with trees about 2 miles southwest of the runway threshold.

The FAA inspector's stated that he had arrived at the crash scene at 1500, on June 7, 2002. The "...aircraft was upside down with the right wing separated from the fuselage." The FAA inspector stated that he observed a "faint smell of fuel with little foliage damage." The fuel cells were found "compromised by impact, but there was fuel still in the cells." The propeller tips were "bent uniformly aft" indicating "no power at impact." One blade was separated from the hub.

According to the New Piper Corporation's investigator's preliminary report, he examined the crash site, "...5 days after the accident...no evidence of internal engine failure was noted...indications of fuel spray on the foliage was inconclusive. Numerous branches were broken and the flight path was evident through the trees. No cut branches or prop strikes were noted. Aircraft fueling records were not available at the time of the investigation...further investigation by Lycoming is planned in the near future." (See the copy of the New Piper Corporation's investigator's report, an attachment to this report).

According to the FAA, Airworthiness inspector's statement, he assisted an investigator from Textron Lycoming with the inspection of the engine from N697MA, on June 20, 2002. The inspector stated that "...our preliminary inspection led us [FAA and Lycoming] to the conclusion that engine model IO-540-K1GS; S/N L-25968-48A had an internal failure." (See the copies of the FAA inspector's statements, an attachment to this report).

According to the Textron Lycoming investigator's field notes (no date), "...the engine was rotated...crankshaft continuity was established, but no valve train continuity could be verified. The vacuum pump was removed and the accessory housing was inspected using a lighted bore scope, and no accessory gear movement was observed. All cylinders were inspected using a lighted bore scope, all pistons were observed rotating properly. The oil measuring gauge reveled 6.5 quarts of what appeared to be engine oil, no contaminants were noted...at this point in the investigation, it was decided that the inspection should be discontinued and the engine be removed and returned to Textron/Lycoming for further teardown inspection." (See the copy of the Textron/Lycoming investigator's report, an attachment to this report).

On July 15, 2002, the engine from N697MA was disassembled under the supervision of the FAA at the facilities of Lycoming Engines, Williamsport, Pennsylvania. The engine examination revealed that the engine failure was due to a broken crankshaft gear bolt, and the separation of the crankshaft gear from the rear of the crankshaft. The crankshaft, crankshaft gear, crankshaft gear bolt, and crankshaft dowel were sent to the Lycoming Materials Laboratory for further evaluation (See the copy of the Textron/Lycoming engine teardown report, an attachment to this report).

The Lycoming Materials Laboratory Report, dated August 6, 2002, revealed that crankshaft bolt part number STD-2209, was "...the primary cause of engine failure." According to the Lycoming Materials Laboratory Technical Report, visual examination revealed the crankshaft gear bolt fractured through "...the second to fifth threads from the shank. Two overlapping cracks extended through approximately 270 degrees of the circumference were also observed in the twelfth and thirteenth threads from the shank." A "possible" crack was observed in the "radius" under the head, and was "confirmed" by fluorescent magnetic particle inspection. "...Intergranular separation on [all the cracks] indicated all were caused by hydrogen assisted cracking [hydrogen embrittlement]." This was based upon the observations of the fatigue on the crack in the second and fifth threads, the location of laboratory-produced overload on cracks in the twelfth and thirteen threads, and the varying depth of intergranular separation on the crack under the head. The Lycoming Materials Laboratory Report further stated, "...SEM-EDAX (energy dispersive x-ray analysis) examination revealed the plating was zinc. Zinc plating per AMS 2402 was allowed as an approved variant to the engineering drawing requirement of cadmium under Textron Lycoming SDMR 78347 approved July 19. 1995." (See the copy of the Textron/Lycoming Materials Laboratory Report, an attachment to this report.)

A history of the engine revealed that the engine was shipped as a new IO-540-K1G5, L-25968-48A from Lycoming Engines, Williamsport, Pennsylvania, to The New Piper Aircraft, Vero Beach, Florida, on December 26, 1996. There were no records indicating that the accident engine was returned to Lycoming until after the accident on June 7, 2002.

The aircraft was released to Mr. Dennis Krueger, on behalf of the owner's insurance company, on July 30, 2002. The engine and crankshaft bolt were released to Mr. Dennis Krueger, on April 16, 2003.

Aircraft

Registration
N697MA
Reported as
Piper PA-32R-301
Category
Airplane
Serial number
3246069
Airframe hours
447.7
Engine
Lycoming IO-540-K1G5, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Mark D. Williams
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 7, 2001 · 42 hours before
Departed
MEI · Meridian, MS
Airport
MEI · Key Field Airport, runway 01, 10,004 × 150 ft, asphalt

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
39
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Last flight review
October 5, 2001
Seat
Left
Flight hours
656 total · 285 in this make and model · 590 as pilot in command · 17 in the last 90 days · 4 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
10° at 5 knots
Visibility
8 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 70 °F
Altimeter
29.97 inHg
Observed at
KMEI

Docket · 8

The files NTSB released with the investigation on April 30, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.5 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.