# NTSB NYC02LA028: Piper PA-28R-200, N3057R, Cattaraugus, NY, November 11, 2001 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: November 11, 2001, 08:50 local (13:50 UTC) - Place: Cattaraugus, NY - Coordinates: 42.404445, -78.847503 - Nearby events: https://openairdocs.org/map.md?lat=42.4044&lon=-78.8475&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report June 4, 2002 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 53763 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC02LA028 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/53763/pdf - Page: https://openairdocs.org/ntsb/NYC02LA028 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, cruise - normal - engine assembly,cylinder - separation (cause) - reason for occurrence undetermined - Forced landing, descent - emergency - On ground/water encounter with terrain/water, landing - roll - terrain condition - hidden obstruction(s) (contributing 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](https://openairdocs.org/aircraft/N3057R), registered now, S/N 28R-35618, built 1970 (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 SER A&C](https://openairdocs.org/engine/lycoming-i0360-ser-a-c) (registry code 41511, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-35618 - Airframe hours: 3191 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 28; injuries: none; 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 - Student pilot; age 39; injuries: none; 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 (OpenAirDocs). - [Accident 20011111031859A](https://openairdocs.org/incident/20011111031859A), Nov 11, 2001: Piper PA28R200, Otto, NY, No damage. (-23) On November 11, 2001, a Piper arrow, PA-28R-200, N3057R, registered to rupp aviation of wauseon, Ohio, was in cruise at 3000 feet, after departing… ## Other investigations on N3057R (1) 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. - [NTSB CHI70DDJ22](https://openairdocs.org/ntsb/CHI70DDJ22), Jun 6, 1970: Piper PA-28R (N3057R), Washington Is, WI, substantial damage 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.