NYC08FA053

NTSB accident investigation · Piper PA-28R-200 · Augusta, GA · December 5, 2007

Accident · FatalField investigationFinal report
Date
December 5, 2007, 18:55 local (23:55 UTC)
Place
Augusta, GA
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N43274Piper PA-28R-200
Weather
Visual (VMC) · Night
Status
Completed · report July 14, 2009
Report
Approved by Office Director
Parties
Piper Aircraft, Lycoming Engines, FAA/FSDO
FAA report
20071205832469A
Case key
67209

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

A loss of engine power due to the fatigue fracture of the number 2 cylinder attach studs, and the subsequent separation of the number 2 cylinder.

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 installation,mounting bolt - fatigue
Engine assembly,cylinder - separation
Forced landingEmergency descent/landing
In flight collision with objectEmergency descent/landing
Object - building(nonresidential)
Terrain condition - none suitable

Analysis

While enroute to the destination airport, the pilot reported to air traffic control that he had a "rough running engine,"and asked where the nearest airport was. He was given vectors for an airport and subsequently reported that the airplane's engine lost power and that he would attempt to land on a road. The airplane touched down in a parking lot and continued to travel for about 50 feet, until it impacted a building and caught fire. A witness reported that the engine sounded as if "all the cylinders weren't firing." Examination of the engine revealed that the number 2 cylinder was displaced from the crankcase and the associated connecting rod was separated from the crankshaft. Examination of the studs used to attach the cylinder to the crankcase revealed that they were fractured due to fatigue. Additionally, continued operation of the engine after the separation of the cylinder fractured the associated connecting rod to produce mechanical damage inside of the crankcase. According to maintenance records, 22 months prior to the accident the engine case was repaired when a crack was noted. The engine was reinstalled and the airplane returned to service two months later, at 977 hours since major overhaul. The most recent 100-hour inspection was performed one month prior to the accident with no anomalies noted. At that time, the engine had accumulated 1409 hours since major overhaul. The investigator could not determine if a specific maintenance action initiated and allowed the fatigue crack.

Factual narrative

History of flight

On December 5, 2007, at 1855 eastern standard time, a Piper PA-28R-200, N43274, was destroyed during a forced landing in Augusta, Georgia. The certificated private pilot was fatally injured. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the flight which originated at the Charleston International Airport (CHS), Charleston, South Carolina and was destined for the Cartersville Airport (VPC), Cartersville, Georgia. The business flight was conducted under 14 CFR Part 91.

According to the operator of the airplane, the pilot had flown from Cartersville to Charleston on the morning of the accident to pick up a prospective employee of the company for an interview. The pilot delivered the applicant to Cartersville around 1200, and departed again around 1515 to return the prospective employee to Charleston when the interview was completed. The pilot departed Charleston for the return flight to Cartersville around 1745.

According to air traffic control information provided by the Federal Aviation Administration (FAA), at 1830, the pilot reported that he had a "rough running engine," and asked where the nearest airport was. The controller subsequently issued vectors for the Daniel Field Airport (DNL), Augusta, Georgia, and cleared the pilot for a "pilot's discretion descent to 2,000 feet." As the pilot was attempting to locate DNL, he reported that his engine "quit," and he would attempt to land on a road or highway. No further transmissions were received from the pilot, and radar contact was lost with the airplane about two miles north-northwest of DNL.

According to a witness, he was standing outside a home, approximately 10 miles from DNL, when he first heard the airplane. He stated the airplane was making a "terrible sound," and was headed southeast, across his field of vision. The engine sounded like the "RPM was going up and down," and then started to "miss." He stated the airplane was at an altitude about 300 feet above the ground, and descending toward DNL. As the airplane crossed over where he was standing, he thought the engine sounded as if "all the cylinders weren't firing." The witness lost sight of the airplane as it continued toward the airport.

Personnel information

The pilot held a private pilot certificate with ratings for airplane single engine land and instrument airplane. His most recent FAA first-class medical certificate was issued on June 13, 2007. At that time, he reported 160 hours of total flight experience.

The pilot's logbook was not located; however, records provided by the operator indicated the pilot flew the accident airplane 66 total hours between January 2006 and the accident. In the previous 90 days, he accumulated 33 hours in the accident airplane.

Aircraft information

Examination of the engine logbooks revealed that the most recent 100-hour inspection was completed on November 14, 2007, with no anomalies noted. At that time, the engine had accumulated 1,409 hours since major overhaul. The airplane flew 38 additional hours between the 100-hour inspection and the accident.

An entry in the engine logbook, on February 24, 2006, stated, "found cracked case, first case bolt forward of oil pan in left half...." The engine was removed from the aircraft and disassembled, and the crankcase was sent to a separate facility to be repaired. On April 6, 2006, the engine was reinstalled and the airplane was returned to service, at 977 hours since major overhaul.

Meteorological information

The weather reported at Augusta Regional Airport, Augusta, Georgia, 10 miles from the accident site, at 1853, included wind from 230 degrees at 6 knots, 10 miles visibility, clear skies, temperature 14 degrees Celsius (C), dew point -08 degrees C, and altimeter setting 29.73 inches of mercury.

Wreckage and impact information

The initial impact point was a scrape mark, with white paint transfer, in a parking lot across the side street from the main wreckage. The wreckage path continued approximately 18 feet to additional white scrape marks in the pavement of the parking lot. Three propeller slash marks were noted in the pavement of the side street, approximately 14 feet further along the wreckage path. A broken metal signpost and the right main landing gear were found on a grass area, in the vicinity of the slash marks on the pavement.

The main wreckage came to rest approximately 15 feet from the broken signpost, at the base of a building. The right wing remained intact, and damage consistent with contact with the pavement was observed on the trailing edge of the wingtip. The right flap and aileron remained attached to the wing, and a "crease" was noted at the midpoint of the wing, perpendicular to the wing chord. The right wing fuel tank cap was secured to the wing and fuel remained in the tank.

The empennage remained intact; however, the vertical stabilizer exhibited fire damage. Streaks of oil roughly aligned with the longitudinal axis of the airplane were noted on the vertical stabilizer.

The left wing, cockpit, and fuselage were completely consumed by fire.

Flight control continuity was confirmed from the right aileron to the cockpit, and the flight control cables were traced from the vicinity of the left aileron to the cockpit. Flight control continuity was also confirmed from the empennage flight control surfaces to the cockpit.

The engine remained attached to the firewall, and the propeller remained attached to the engine. Examination of the propeller blades revealed slight S-bending, and the blade tips were curled aft. The number 2 cylinder was displaced from the crankcase, and the associated connecting rod was separated from the crankshaft. Additionally, two pieces of the crankcase, in the area of the connecting rod, were separated from the case. One piece was located in the vicinity of the engine and one piece was located approximately 20 feet from the engine. Both pieces displayed damage consistent with contact with the connecting rod. The number 2 connecting rod cap was separated into two sections. One section was recovered at the accident site with the bolt attached. A nut was also recovered at the site, but not attached to the cap. The remaining rod cap section was not recovered.

The engine was removed from the airframe and further examined. The number 2 cylinder was removed and valve train continuity was confirmed to the remaining 3 cylinders. The engine was further disassembled and damaged was noted to the camshaft and crankshaft throw, in the vicinity of the number 2 connecting rod. Damage was also noted to the interior of the crankcase, in several locations.

The fuel injector servo was examined, and the throttle control was in the "idle" position, the mixture control was in the "mid-range" position, and the inlet screen was absent of debris.

The remaining engine accessories were severely impact and fire damaged, and could not be tested.

Medical and pathological information

The Georgia Bureau of Investigation, Division of Forensic Sciences, performed an autopsy on the pilot on December 7, 2007. The cause of death was smoke, soot and superheated gas inhalation.

The FAA Bioaeronautical Research Laboratory, Oklahoma City, Oklahoma conducted toxicological testing on the pilot. No drugs or alcohol were detected during the testing.

Tests and research

The number 2 cylinder, both crankcase halves, and the attaching hardware were sent to the NTSB Materials Laboratory in Washington D.C. for examination. The examination revealed the studs used to attach the number 2 cylinder to the crankcase, displayed fractures consistent with fatigue. Examination of the crankcase halves revealed mechanical damage on the number 2 cylinder mounting flange and mechanical damage on internal surfaces adjacent to the number 2 cylinder location. A majority of the mechanical damage on the mounting flange consist

Aircraft

Registration
N43274
Reported as
Piper PA-28R-200
Category
Airplane
Serial number
28R-7435259
Airframe hours
2,704
Engine
Lycoming IO-360, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Business · Part 91
Operator
Pheonix Air
Registered owner
VPC Air
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · November 14, 2007 · 38 hours before
Departed
CHS · Charleston, SC
Destination
VPC · Cartersville, GA
Flight plan
IFR

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
19
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
208 total · 33 in the last 90 days · 13 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
230° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
57 °F, dew point 18 °F
Altimeter
30.00 inHg
Observed at
AGS, 10 nm away

Docket · 17

The files NTSB released with the investigation on May 12, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.2 MB in all.

FAA reports on this event · 1

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