# NTSB MIA95LA127: Piper PA-32-260, N3482W, N. Miami Beach, FL, May 5, 1995 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: May 5, 1995, 10:24 local (14:24 UTC) - Place: N. Miami Beach, FL - Coordinates: 25.959823, -80.179374 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=25.9598&lon=-80.1794&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report September 24, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 37764 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA95LA127 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/37764/pdf - Page: https://openairdocs.org/ntsb/MIA95LA127 ## Probable cause INADEQUATE ANNUAL INSPECTION BY MAINTENANCE PERSONNEL FOR FAILURE TO IDENTIFY A HARDENED OIL HOSE FROM THE OIL PUMP TO THE OIL COOLER INLET INSIDE A PROTECTIVE FIRE SLEEVE. ADDITIONALLY, UNSUITABLE TERRAIN ENCOUNTERED DURING THE FORCED LANDING CONTRIBUTED TO THE ACCIDENT. ## 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, climb - to cruise - lubricating system,oil hose - failure,total - maintenance,annual inspection - inadequate, other maintenance personnel (cause) - fluid,oil - exhaustion - engine assembly,connecting rod bolt - failure - Forced landing, emergency descent/landing - Ditching, emergency landing - terrain condition - none suitable (contributing factor) ## Analysis SHORTLY AFTER TAKEOFF THE PILOT OBSERVED THAT THE OIL PRESSURE BEGAN DECREASING. HE TURNED TO RETURN TO THE DEPARTURE AIRPORT BUT THE ENGINE FAILED AND THE AIRPLANE CRASHED INTO A LAKE NEAR THE AIRPORT. THE AIRPLANE WAS RECOVERED AND EXAMINATION OF THE ENGINE REVEALED THAT AN OIL HOSE FROM THE OIL PUMP TO THE OIL COOLER INLET FAILED IN TWO PLACES INSIDE THE PROTECTIVE FIRE SLEEVE. THE FIRE SLEEVE WAS OIL SOAKED AND INTERNALLY FOUND TO CONTAIN METAL PARTICLES. THE FAILED OIL HOSE WAS MANUFACTURED IN THE THIRD QUARTER OF 1987 AND INSTALLED FOLLOWING ENGINE OVERHAUL ON JULY 22, 1987. FURTHER EXAMINATION OF THE ENGINE REVEALED THAT THREE OF THE SIX CYLINDER CONNECTING RODS FAILED DUE TO LACK OF LUBRICATION. THE REMAINING THREE CONNECTING RODS WERE FOUND TO BE HEAT DISTRESSED AND THEIR ASSOCIATED ROD BEARINGS EXTRUDED. REVIEW OF THE ENGINE LOGBOOK REVEALED THAT THE ENGINE HAD BEEN OPERATED FOR ABOUT 53 HOURS SINCE THE LAST INSPECTION IN NOVEMBER 1994. ## Factual narrative On May 5, 1995, about 1024 eastern daylight time, a Piper PA-32-260, N3482W, registered to R & D Aero Service, Inc., crashed in a lake shortly after takeoff from the Opa-Locka Airport, Opa-Locka, Florida, while on a 14 CFR Part 91 personal flight. Visual meteorological conditions prevailed at the time and a VFR flight plan was filed for the flight to Nassau, Bahamas. The airplane was substantially damaged and the commercial-rated pilot, the sole occupant, sustained minor injuries. The flight originated about 1020. The pilot stated that when the flight was about 1/2 mile west of the shoreline at 1,300 feet [mean sea level] flying eastbound, he observed that the oil pressure began decreasing. He turned to return and observed that the oil pressure indicating needle was "in the red." Unable to maintain altitude and land at the departure airport, he crashed the airplane into a lake about 4 nautical miles east-northeast from the departure airport. The airplane was recovered from the lake and examination revealed that the right wing separated at the wing root. Additionally, oil stains were noted on the left side of the fuselage aft of the engine assembly and also on the bottom of the fuselage. The engine was removed from the airplane for further examination. Examination of the engine revealed that an oil hose from the engine-driven oil pump to the oil cooler inlet failed in two places inside the fire sleeve. The fire sleeve was found to be oil soaked and contained metal particles. The data tag attached to the failed oil hose indicated that it was manufactured in the third quarter of 1987 and pressure tested in July 1987. Examination of the failed hose revealed that it was hardened. Further examination of the engine revealed that cylinder Nos. 4, 5, and 6 connecting rods failed at the crankshaft end due to lack of lubrication. Cylinder Nos. 1, 2, and 3 connecting rods were still secured to the crankshaft, however, their associated bearings were extruded and the connecting rods were heat distressed. All oil passages in the crankshaft and crankcase halves were found to be free of obstructions. The oil pump gears were found to be intact, however, slight scoring was observed on the inside of the oil pump housing. Metal was observed in the paper element of the spin on oil filter which was properly torqued and metal was also observed in the oil suction screen. Examination of the main bearings of the crankshaft revealed that they were not heat distressed. Review of the engine logbook revealed that the engine was overhauled on July 22, 1987, and installed in the airplane on August 5, 1987. The associated entry in the engine logbook revealed that new customer supplied oil hoses were installed when the engine was installed. The engine was last inspected on November 28, 1994. The mechanic who performed the inspection indicated that he used the scope and detail of items in Appendix D of 14 CFR Part 43 as a reference. The engine had been operated for about 53 hours since the last inspection in November. ## Aircraft - Registration: [N3482W](https://openairdocs.org/deregistered/N3482W-2013-10-23), registration cancelled 2013-10-23, S/N 32-359, built 1966 (OpenAirDocs) - Reported make and model: PIPER PA-32-260 - Registry model: [Piper PA-32-260](https://openairdocs.org/model/piper-pa-32-260) (registry code 7103206) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 32-359 - Airframe hours: 4876 - Engines: LYCOMING O-540-E4B5 260 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Tynes, Kevin E. - Registered owner: R & D Aero Service, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 28, 1994, 53 hours before - Departed: OPF, OPA LOCKA, FL - Destination: MYN, NASSAU, OF - Flight plan: VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 24; private, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 293 total ## Weather - Conditions: Visual (VMC), Day - Wind: 340° at 5 knots - Visibility: 8 statute miles - Lowest ceiling: 20,000 ft overcast - Altimeter: 30.00 inHg - Observed at: OPF, 4 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 (OpenAirDocs). - [Accident 19950505013759A](https://openairdocs.org/incident/19950505013759A), May 5, 1995: Piper PA32260, Miami, FL, Substantial damage. Enroute to nassau lost oil pressure. Crash landed in lake returning. Oil cooler hose broke. Lost all oil. 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.