NYC08LA086

NTSB accident investigation · Piper PA-28-R200 · York, SC · January 25, 2008

Accident · Minor injuriesLimited investigationFinal report
Date
January 25, 2008, 12:10 local (16:10 UTC)
Place
York, SC
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N1939TPiper PA-28-R200
Defining event
Enroute-climb to cruise: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report May 6, 2009
Report
Approved by Office Director
Parties
Lycoming Engines, FAA/FSDO, Piper Aircraft
FAA report
20080125831359A
Case key
67429

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

Loss of engine power due to improper welding of the crankcase, which resulted in fatigue failure of the through-studs and a subsequent separation of the number two cylinder. Contributing to the accident was the unsuitable terrain for a forced landing.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

MaintenancePersonnel issues › Task performance · Maintenance personnelPiper PA-28R-200: 2 casesAll aircraft: 143 casesProbable cause
TerrainEnvironmental issues › Physical environment · Contributed to outcomePiper PA-28R-200: 1 caseAll aircraft: 267 casesProbable cause
Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · Incorrect service/maintenancePiper PA-28R-200: 4 casesAll aircraft: 373 casesProbable cause
Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · Fatigue/wear/corrosionPiper PA-28R-200: 4 casesAll aircraft: 373 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

Shortly after departure, while climbing through 4,000 feet, the airplane experienced a "sudden and violent shuddering," followed by smoke penetration into the cockpit. The pilot performed a forced landing to a field, during which the airplane was substantially damaged. Examination of the engine revealed the number two cylinder had separated from the engine crankcase and the through-bolts that attached the cylinder to the crankcase were fractured due to fatigue. Evidence of welding in the cylinder deck area of the crankcase was observed, which produced a soft condition in the cylinder mounting flanges and subsequent non-standard loading and fatigue fracture of the studs. The engine manufacturer does not allow welding in the critical cylinder deck area of the crankcase. According to the engine maintenance records, the engine was overhauled 2 years prior to the accident and had accumulated 679 hours since then.

Factual narrative

On January 25, 2008, at 1210 eastern standard time, a Piper PA-28-R200, N1939T, was substantially damaged during a forced landing in York, South Carolina. The certificated private pilot and passenger received minor injuries. Visual meteorological conditions prevailed, and no flight plan was filed for the flight that originated at Rock Hill Airport (UZA), Rock Hill, South Carolina, and was destined for Asheville Airport (AVL), Asheville, North Carolina. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

According to the pilot, he departed UZA, and while climbing through 4,000 feet, the airplane experienced a "sudden and violent shuddering," followed by smoke penetration into the cockpit. The pilot turned toward York Airport (01SC), and prepared for an emergency landing. He pulled the mixture control to the idle cut-off position and turned the master switch to "off." When the pilot realized he would not be able to reach the airport, he located a field adjacent and to the east of the airport, and performed a forced landing. During the landing rollout, the nose wheel dug into the soft ground and the airplane abruptly came to rest.

Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed the wings were substantially damaged. Examination of the Lycoming IO-360 engine revealed the number 2 cylinder had separated from the engine crankcase and the cylinder hold down nuts were broken off of the base studs. The base of the number 2 cylinder, as well as the engine crankcase, displayed fretting as well as a substantial amount of impact damage from the cylinder and connecting rod. No discoloration or heat distress was noted on any of the parts.

The number 2 cylinder, associated through-bolts, and the threaded end of a stud, still held in a nut, were sent to the National Transportation Safety Board Metallurgical Laboratory for further examination. The examination noted fatigue cracking on both of the through-bolts and on the threaded end of the stud still in the nut. The damage to the cylinder, piston, and connecting rod was determined to be secondary to the fatigue cracking in the bolts and studs.

The entire engine was further examined at the Lycoming factory under the supervision of a Safety Board investigator. The examination of the crankcase revealed evidence of welding repairs on the outside of both crankcase halves, and the interior surfaces near the number 2 cylinder. According to Lycoming engineering documents, welding should not be performed inside the critical cylinder deck area. Additionally, the crankcase hardness was measured in two locations on the number 2 cylinder mounting flange. Both locations measured well below the minimum hardness requirements on all Lycoming crankcase engineering drawings.

Examination of the four crankcase through-studs revealed they were yellow in color, compared to the standard silver-gray color of through-studs manufactured by Lycoming. Additionally, the threaded length of the studs was required to be a minimum length of 0.840 inches. The subject studs were measured to be 0.66-0.68 inches in length. One of the unbroken studs was subjected to a tensile test, in which it measured 169.4 ksi (with a maximum load of 21,500 pounds). A sampling of 19 through-studs from 2005-2008 receiving inspection at Lycoming ranged in strength from 172.6-180.9 ksi, with an average of 177.4 ksi.

According to the airplane and engine logbooks, the engine was overhauled and reinstalled on the airplane on January 27, 2006. During the overhaul, the crankcase was sent to another facility for overhaul. The crankcase overhaul facility could not provide records of the work performed.

The airplane's most recent 100-hour inspection was completed on August 22, 2007. At that time, the airplane had a tach time of 3,329 hours, and 586 hours since major overhaul (SMOH). At the time of the accident, the airplane had accumulated 679 hours SMOH.

Aircraft

Registration
N1939T
Reported as
Piper PA-28-R200
Category
Airplane
Serial number
28R-7135137
Airframe hours
3,329
Engine
Lycoming IO-360, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Rock Hill Aviation
Registered owner
Dougrace LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 1, 2007
Departed
UZA · Rock Hill, SC
Destination
AVL · Ashville, NC

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
37
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
January 1, 2007
Seat
Left
Flight hours
127 total · 30 in this make and model · 81 as pilot in command · 4 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
30 °F, dew point 3 °F
Altimeter
30.51 inHg
Observed at
UZA, 10 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.