# NTSB MIA91LA115: Piper PA-28-181, N8156E, Vero Beach, FL, April 3, 1991

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: April 2, 1991, 21:15 local (Apr 3, 1991, 02:15 UTC)
- Place: Vero Beach, FL
- Coordinates: 27.720787, -80.389503 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=27.7208&lon=-80.3895&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 4 uninjured
- Status: Completed, report January 25, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 32845
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA91LA115
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/32845/pdf
- Page: https://openairdocs.org/ntsb/MIA91LA115

## Probable cause

FAILURE OF MAINTENANCE PERSONNEL TO FOLLOW DIRECTIONS OF A SERVICE BULLETIN DURING THE MAJOR OVERHAUL OF THE ENGINE. THIS RESULTED IN FAILURE TO DETECT A FOREIGN OBJECT UNDER THE CRANKSHAFT GEAR.  AS A RESULT THE CRANKSHAFT GEAR BECAME LOOSE AND QUIT TURNING RESULTING IN THE TOTAL LOSS OF ENGINE POWER.

## 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 - normal
  - accessory drive assy,drive gear - foreign object (cause)
  - maintenance,service bulletin/letter - not followed, other maintenance personnel (cause)
  - maintenance,overhaul,major - poor, other maintenance personnel
  - accessory drive assy,drive gear - failure,total
- Forced landing, descent - emergency
- On ground/water collision with object, landing - roll
  - object - tree(s)
  - object - other

## Analysis

WHILE ON A SHORT CROSS COUNTRY FLT, THE ENG QUIT.  THE PLT WAS UNABLE TO RESTART THE ENG.  DURING THE FORCED LANDING ON A ROAD, THE ACFT COLLIDED WITH A TREE THEN A GUARDRAIL. EXAM OF THE ENG REVEALED THAT THE CRANKSHAFT GEAR WHICH DRIVES TWO CRANKSHAFT IDLER GEARS WHICH IN TURN DRIVES EACH MAGNETO DRIVE GEAR FAILED TO DO SO WHEN THE BOLT WHICH SECURES IT TO THE CRANKSHAFT BACKED OUT ABOUT THREE TURNS. THIS WAS DUE TO A FOREIGN OBJECT LOCATED UNDER THE GEAR FOR AN UNDETERMINED TIME.  THE LOOSE BOLT RESULTED IN THE TORQUE FROM THE CRANKSHAFT BEING TRANSMITTED TO THE CRANKSHAFT ALIGNMENT DOWEL, WHICH IS A NON-LOAD CARRYING MEMBER.  THE ALIGNMENT DOWEL FAILED DUE TO FATIGUE RESULTING IN THE TOTAL LOSS OF ENG POWER.  THE FOREIGN OBJECT WAS REPORTEDLY NOT LOCATED.  REVIEW OF THE ENG LOGBOOKS REVEALED THAT THE ENG WAS OVERHAULED 1,574 HRS EARLIER.

## Aircraft

- Registration: N8156E (not matched to a registry record)
- Reported make and model: PIPER PA-28-181
- Category: Airplane
- Serial number: 28-8290102
- Airframe hours: 3602
- Engines: LYCOMING O-360-A4M 180 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Operator: Sun Aviation, Inc.
- Registered owner: Vero Air Rental, Inc.
- Last inspection: 100 hour, January 25, 1991, 87 hours before
- Departed: 2RR, RIVER RANCH, FL
- Destination: VRB, VERO BEACH, FL

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 42; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; flight hours: 121 total, 121 in this make and model, 48 as pilot in command, 44 in the last 90 days, 26 in the last 30 days

## Weather

- Conditions: Visual (VMC), Night/dark
- Wind: 60° at 13 knots
- Visibility: 7 statute miles
- Lowest ceiling: none
- Temperature: 79 °F

## 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 19910402026039A](https://openairdocs.org/incident/19910402026039A), Apr 2, 1991: Piper PA28181, Vero Beach, FL, Substantial damage. Crankshaft gear dowel failed causing power loss and forced landing. Gear not properly installed on engine overhaul.

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.

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