NYC02LA028

NTSB accident investigation · Piper PA-28R-200 · Cattaraugus, NY · November 11, 2001

Accident · No injuriesLimited investigationFinal report
Date
November 11, 2001, 08:50 local (13:50 UTC)
Place
Cattaraugus, NY
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N3057RPiper PA-28R-200
Weather
Visual (VMC) · Day
Status
Completed · report June 4, 2002
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20011111031859A
Case key
53763

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

A separation of the cylinder from the engine for undetermined reason(s). A factor was the hidden ground obstruction (hole) which the airplane struck during the landing roll.

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(total) - mech failure/malfCruise - normal
Engine assembly,cylinder - separationCause
Reason for occurrence undetermined
Forced landingDescent - emergency
On ground/water encounter with terrain/waterLanding - roll
Terrain condition - hidden obstruction(s)Factor

Analysis

During en route cruise, the airplane's engine began to run rough. This was followed by a loud bang, and a cylinder penetrated the engine cowling. A forced landing was performed to a field. During the ground roll, one main landing gear struck a hole, after which, it collapsed. The airplane yawed, and the other main landing gear also collapsed. Examination revealed that the number 3 cylinder had pulled away from the engine case. All through bolts and engine case bolts were separated. In addition, the piston and piston wrist pin were fractured. Oil was found in the engine sump. Maintenance records revealed that the cylinders had been removed and replaced 146 hours prior to the occurrence. The mechanic who performed the installation was interviewed by the FAA and found to be knowledgeable on the tightening procedures recommended by Lycoming.

Factual narrative

On November 11, 2001, about 0850 eastern standard time, a Piper PA-28R-200, N3057R, was substantially damaged during a forced landing near Cattaraugus, New York. The certificated flight instructor, private pilot, and a passenger were not injured. Visual meteorological conditions prevailed. No flight plan had been filed for the instructional flight that was conducted under 14 CFR Part 91.

According to the pilots, the flight originated November 10, 2001, from Lenawee County Airport, Adrian Michigan, as a dual instructional cross-country flight. The airplane remained overnight at Weedsport, New York. The next morning, the flight departed Weedsport about 0750, for Jamestown, New York. The flight instructor further stated:

"...An hour into the flight the aircraft [engine] began running rough. We then turned alternate air on, mixture rich, fuel pump on, and began looking for the nearest airport which was Berdick, a private strip near Otto, NY. Soon after, we heard a bang and could see...[a] hole in the cowling caused by the cylinder. After that, smoke started coming in the vents. We shut the heat and defrost off. For a brief time flames could be seen through the hole. We immediately started turning toward the nearest field. Once the landing was assured...[the private pilot] began shutting the aircraft down - (mixture cut-off, fuel off, master off), and added flaps while I flew the plane to the ground. We had everyone secure themselves and brace for touchdown. Once the aircraft was on the ground...[the private pilot] retracted the flaps and began braking on the rollout. Then in the rollout the right gear sank into the woodchuck hole and broke off as the aircraft slid to a stop; the side load broke the left gear. The gear breaking off caused skin damage to the right wing. Once the aircraft stopped, we evacuated the aircraft. The field was a grass meadow with a rise in the center.

According to an inspector from the Federal Aviation Administration (FAA), the number 3 cylinder had pulled away from the engine case. All through bolts and engine case bolts were separated. In addition, the piston and piston wrist pin were fractured. Oil was found in the engine sump.

According to logbook records, on March 16, 2001, all of the cylinders were removed, repaired, and reinstalled in accordance with the Lycoming overhaul manual. At the time of the accident, the engine had accumulated 146.7 hours since the cylinder removal and re-installation.

Lycoming Service Instruction 1029D, dated August 15, 1986 stated:

"All Avco Lycoming aircraft engines incorporate bolts and long thru studs that extend through the crankcase halves primarily for holding them together. The studs also secure the cylinders to their mounting decks on the crankcase...."

"To insure uniform loading on the main bearing, it is necessary to tighten these studs and bolts in a sequence beginning at the approximate center of the engine and progressing evenly to both front and rear of the engine as described in detail in the following procedures"

The mechanic who performed the cylinder installation was interviewed by another FAA inspector. According to the inspector's statement:

"...[the mechanic] was knowledgeable on Lycoming Service Instruction SI 1029D, and knew how to implement it....."

Aircraft

Registration
N3057R
Reported as
Piper PA-28R-200
Category
Airplane
Serial number
28R-35618
Airframe hours
3,191
Engine
Lycoming IO-360-C1C, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Registered owner
HB Aviation & Leasing
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 18, 2001 · 37 hours before
Departed
B16 · Weedsport, NY
Destination
JHW · Jamestown, NY

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
28
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
January 29, 2001
Seat
Right
Flight hours
1,669 total · 50 in this make and model · 1,564 as pilot in command · 137 in the last 90 days · 54 in the last 30 days · 4 in the last 24 hours
Role
Student pilot
Age
39
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Last flight review
August 14, 2001
Seat
Left
Flight hours
207 total · 19 in this make and model · 164 as pilot in command · 51 in the last 90 days · 22 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
340° at 9 knots
Visibility
15 statute miles
Lowest ceiling
3,000 ft broken
Temperature
32 °F, dew point 21 °F
Altimeter
30.22 inHg
Observed at
JHW, 24 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.

Other investigations on N3057R · 1

Matched to the same aircraft by N-number and date.