# NTSB NYC00LA082: Piper PA-28R-200, N4531F, Mount Holly, NJ, February 16, 2000 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: February 16, 2000, 10:00 local (15:00 UTC) - Place: Mount Holly, NJ - Location: 39.9929° N, 74.7877° W: Placed by OpenAirDocs: center of Mount Holly, NJ, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=39.9929&lon=-74.7877&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report December 4, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 48651 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC00LA082 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/48651/pdf - Page: https://openairdocs.org/ntsb/NYC00LA082 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, takeoff - induction air control,intake manifold - disconnected (cause) - maintenance - improper, unknown (cause) - Forced landing, emergency 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](https://openairdocs.org/aircraft/N4531F), registered now, S/N 28R-7635415, built 1976 (OpenAirDocs) - Reported make and model: Piper PA-28R-200 - Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7635415 - Airframe hours: 5210 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 36; 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 (OpenAirDocs). - [Accident 20000216040959A](https://openairdocs.org/incident/20000216040959A), Feb 16, 2000: Piper PA28R200, Mount Holly, NJ, No damage. (-23)See attached comment text for ptrs ea 17200005320 and inspectors statement for inspector john penzone. Further investgation of aircraft records will… 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.