MIA96LA142

NTSB accident investigation · Piper PA-32 · Jacksonville, FL · May 20, 1996

Accident · Serious injuriesLimited investigationFinal report
Date
May 20, 1996, 14:35 local (18:35 UTC)
Place
Jacksonville, FL
Injuries
1 serious, 2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N9164BPiper PA-32
Weather
Visual (VMC) · Day
Status
Completed · report December 16, 1996
Report
Approved by Office Director
FAA report
19960520010939A
Case key
38020

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 pilot's failure to maintain airspeed (VSO) while maneuvering during a go-around, resulting in an inadvertent stall and subsequent in-flight collision with terrain. Contributing to the accident was the pilot's failure to achieve the proper touchdown point during an emergency landing, his decision to make a go-around with a known mechanical deficiency (partial loss of engine power) due to the improper installation of the piston plugs during assembly of the engine by the manufacturer.

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/malfClimb - to cruise
Engine assembly,piston - improperFactor
Loss of engine power(partial) - mech failure/malfEmergency landing
Airspeed - excessivePilot in commandFactor
Proper touchdown point - not obtainedPilot in commandFactor
Go-around - performedPilot in command
Loss of control - in flightGo-around (vfr)
Airspeed(vso) - not maintainedPilot in commandCause
Stall - inadvertentPilot in command
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The pilot made an emergency landing to an airport after informing ATC that the engine had sustained a partial loss of engine power. Witnesses observed the airplane touch down extremely fast, long, and initiate a go-around. The airplane was observed in a nose high, climbing right turn, and a lack of airspeed. The nose dropped down, and the airplane collided with the trees and terrain in a nose down attitude. Disassembly of the engine revealed the piston plugs on the Nos.3 and 5 cylinders were installed on the forward sides of both pistons. This allowed the unprotected ends of the pins to rub against the cylinder walls. The remaining cylinder assemblies were correctly installed. Review of the engine logbook revealed the engine had not been disassembled since assembly by the manufacturer.

Factual narrative

On May 20, 1996, about 1435 eastern daylight time, a Piper PA-32, N9164B, registered to SAF T Flyers Inc., operating as a 14 CFR Part 91 personal flight, crashed during a forced landing in the vicinity of Jacksonville, Florida. Visual meteorological conditions prevailed and an IFR flight plan was filed. The airplane sustained substantial damage. The commercial pilot sustained serious injuries, and the two passengers sustained minor injuries. The flight originated from Craig Municipal Airport, Jacksonville, Florida, about 5 minutes before the accident.

The pilot stated to the FAA, he departed Craig, IFR en route to Vero Beach, Florida. Shortly after being handed off to departure control, he advised the controller that two engine cylinders had stopped producing power. The controller provided radar vectors back to Craig, and he made a visual no flap approach to runway 32. The approach was "extremely hot." He attempted to reduce engine power with negative results. The airplane touched down half way down the runway at about 80 knots, and started sliding and fishtailing from left to right. He initiated a go-around, became airborne, and made a climbing right turn in an attempt to return to the airport; however the engine was not producing sufficient power to sustain flight, and he elected to make a forced landing to a highway. The airplane appeared to descend rapidly as if in a stall, and impacted with trees and the ground.

The General Aviation Manager for the Jacksonville Port Authority, located at Craig Airport, stated he was at the fire station when the control tower informed them about N9164B. He left the fire station in a fire truck and went to the vicinity of runway 32. N9164B was observed on about a 1 mile final. The airplane crossed the end of the runway very fast , touched down about 1,000 feet down the runway on the nose wheel, and "wheel barrowed" for some distance. "The aircraft reached the end of runway 32, and lifted back into the air and climbed straight ahead to approximately 100 to 200 feet and started a right turn. I knew the airplane would not make it because of the nose high attitude and lack of airspeed. The airplane started to descend and the right turn increased, and the nose dropped to about 30 to 40 degrees nose low and went into the trees."

Review of the engine logbook revealed the engine has not been disassembled since it was manufactured. The engine has accumulated 920 total hours.

Examination of the crash site by the FAA revealed the airplane collided with trees in a nose low attitude and came to rest on a heading of 190 degrees magnetic. The propeller and engine assembly separated and was displaced to the right of the main wreckage. Torsional twisting, "s" bending and chordwise scarring was present on all propeller blades. All propeller blades were bent aft and two propeller blade tips were curled forward. The left wing separated at the wing root and the right wing remained attached to the cabin structure. The left fuel tank was ruptured, and the right fuel tank was not ruptured.

Examination of the airframe, flight control system, and flight control quadrant revealed no evidence of a precrash mechanical failure or malfunction. All components necessary for flight were present at the crash site. Continuity of the flight control system was confirmed for pitch, roll, and yaw.

Examination of the engine assembly by the FAA revealed the rocker arms on the No. 1 and No. 2 cylinders would not operate when the crank shaft was rotated by hand. All engine cylinders were removed to examine cam shaft condition and operation. The piston in the No. 5 cylinder had a large section of the piston skirt and internal areas of the piston pin boss missing. The piston pin plugs were installed on the forward side of the piston allowing the unprotected ends of the pins to rub against the cylinder. Examination of the No. 3 piston revealed the piston pin plugs were installed in the same configuration, however, the piston bosses had not failed. The remaining cylinder assemblies were correctly installed.

Examination of the No.3 and No. 5 cylinder assemblies was performed by the NTSB materials laboratory. The examination revealed that the two piston plugs were installed on the forward sides of both pistons allowing the unprotected ends of the pins to rub against the cylinder walls. The No. 5 cylinder outer portion of the pin boss was broken off on the aft side of the cylinder. Binocular microscopic examination revealed that the fracture was not covered with combustion deposits and contained no evidence of preexisting cracking. Further examination disclosed that the inner portions of both the aft and forward pin bosses were also broken off indicative of fatigue cracking. (For additional information, see NTSB Metallurgist's Factual Report No. 96-163.)

The No. 3 and No. 5 cylinder and piston assemblies were released to Faith A. Collins, Sample International, on October 7, 1996.

Aircraft

Registration
N9164B
Reported as
Piper PA-32
Category
Airplane
Serial number
3206047
Airframe hours
761
Engine
Lycoming IO-540-K1G5, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Roger C. Doerr
Registered owner
Saf T Flyers Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 17, 1995 · 65 hours before
Departed
CRG
Destination
VRB · Verro Beach, FL
Flight plan
IFR
Airport
CRG · Craig Municipal, runway 32, 4,007 × 100 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
58
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Expired
Seat
Left
Flight hours
1,450 total · 425 in this make and model · 1,325 as pilot in command · 10 in the last 90 days · 10 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
130° at 9 knots
Visibility
7 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 70 °F
Altimeter
29.00 inHg
Observed at
CRG, 1 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.