NYC00LA082

NTSB accident investigation · Piper PA-28R-200 · Mount Holly, NJ · February 16, 2000

Accident · No injuriesLimited investigationFinal report
Date
February 16, 2000, 10:00 local (15:00 UTC)
Place
Mount Holly, NJ
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N4531FPiper PA-28R-200
Weather
Visual (VMC) · Day
Status
Completed · report December 4, 2000
Report
Approved by Office Director
FAA report
20000216040959A
Case key
48651

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

Engine failure due to the disconnection of the intake manifold from the #3 cylinder, as a result of improper maintenance.

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 powerTakeoff
Induction air control,intake manifold - disconnectedCause
Maintenance - improperUnknownCause
Forced landingEmergency landing after takeoff

Analysis

After departure, at an altitude of 350 feet above the ground, the engine experienced a total power loss, and the pilot performed an emergency landing in a field. Examination of the engine revealed that the #3 cylinder intake manifold tube was disconnected from the engine and lying in the cowling. The bottom portion of the tube appeared to be 'flattened.' The bolts and washers which connect the intake manifold tube to the cylinder were not found, as well as the 'o-ring' which connects the tube to the manifold. The inspector observed 'flakes,' or metal shavings, in the induction box of the intake manifold. The 'flakes' were consistent with the material of the intake manifold tube. The inspector reported the #3 exhaust manifold was broken at the muffler and appeared worn. The accident engine was installed on the accident airplane on September 20, 1999, at which time an annual inspection was also performed. No additional entries were made in either the airframe or the engine logbooks. At the time of the accident, the engine had flown 96 hours since major overhaul, and had accumulated 1,197 total flight hours.

Factual narrative

On February 16, 2000, about 1000 Eastern Standard Time, a Piper PA-28R-200, N4531F, was substantially damaged during a forced landing in a field, after takeoff from the South Jersey Regional Airport (7MY), Mount Holly, New Jersey. The certificated private pilot was uninjured. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight conducted under 14 CFR Part 91.

The pilot stated that the purpose of the flight was to practice maneuvers in the local area, in preparation for his commercial checkride. When he arrived at the airport, the pilot was informed that the accident airplane was undergoing maintenance and would be "momentarily down." The pilot observed no abnormalities during the preflight inspection or run-up check. He departed Runway 26, and at 50 feet above the ground, the engine made "backfiring and popping sounds," as it began to loose power. At 350 feet above the ground, the engine experienced a total power loss. The pilot reported that the engine was "not producing enough power to maintain lift."

The pilot established an emergency glide, and prepared for a landing in a field. He extended the landing gear and added full flaps. The airplane touched down in the field, and during the landing rollout, the pilot observed a ditch in front of the airplane. He pulled back on the controls and added full power, "but got nothing." The airplane impacted the ditch, the left main landing gear was torn off, and the airplane slid about 500 feet before it came to rest.

A witness reported that the airplane sounded like it was "missing and sputtering," after takeoff. According to the witness, the airplane attempted to turn around; however, it was losing altitude, and disappeared below the treeline.

According to the mechanic apprentice who worked on the airplane before the accident, discrepancies had been reported with the manifold pressure gauge. On the day of the accident, he opened the cowling of the airplane and noticed that a 3/4" piece of copper tubing for the manifold pressure line was missing. This piece was found in the rubber manifold pressure line. The apprentice then reconnected the rubber tubing to the copper tubing. He stated that the manifold pressure line attaches to the #3 cylinder, and reported no abnormalities with that cylinder. He further stated that he did not observe the connecting bolts because he did not remove the bottom cowling to perform the procedure. The apprentice reported his work was overseen by a licensed mechanic; however, no entries were made in the engine or airframe logbooks for the maintenance that was performed.

According to the licensed mechanic who approved the maintenance work, the apprentice removed only the top cowling, and did not remove any attaching hardware for the #3 cylinder, to perform the procedure. He visually inspected the engine after the maintenance was completed and noticed no abnormalities.

A Federal Aviation Administration inspector, who examined the wreckage, reported that he opened the cowling and observed the #3 cylinder intake manifold tube was disconnected from the engine and lying in the cowling. The bottom portion of the tube appeared to be "flattened." The bolts and washers which connect the intake manifold tube to the cylinder were not found, as well as the "o-ring" which connects the tube to the manifold. The inspector observed "flakes," or metal shavings, in the induction box of the intake manifold. The "flakes" were consistent with the material of the intake manifold tube. The inspector reported the #3 exhaust manifold was broken at the muffler and appeared worn.

Examination of the airframe and engine logbooks revealed that the accident engine received an overhaul inspection on February 20, 1991, and then was placed into "long-term storage." On August 4, 1999, the engine was disassembled, reassembled, and test run. The engine was installed on the accident airplane on September 20, 1999, at which time an annual inspection was also performed. No additional entries were made in either the airframe or the engine logbooks. At the time of the accident, the engine had flown 96 hours since major overhaul, and had accumulated 1,197 total flight hours.

Aircraft

Registration
N4531F
Reported as
Piper PA-28R-200
Category
Airplane
Serial number
28R-7635415
Airframe hours
5,210
Engine
Lycoming IO-360, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Allan Slawsky
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 20, 1999 · 96 hours before
Departed
7MY · Mount Holly, NJ
Airport
7MY · South Jersey Regional, runway 26, 3,911 × 50 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
36
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
516 total · 20 in this make and model · 67 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 9 knots, gusting 15
Visibility
7 statute miles
Lowest ceiling
None
Temperature
45 °F, dew point 34 °F
Altimeter
30.00 inHg
Observed at
VAY

FAA reports on this event · 1

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