# NTSB NYC08LA086: Piper PA-28-R200, N1939T, York, SC, January 25, 2008 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: January 25, 2008, 12:10 local (16:10 UTC) - Place: York, SC - Coordinates: 35.031944, -81.252777 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.0319&lon=-81.2528&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report May 6, 2009 - Report: Approved by Office Director - Parties: Lycoming Engines, FAA/FSDO, Piper Aircraft - NTSB case key (mKey): 67429 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC08LA086 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67429/pdf - Page: https://openairdocs.org/ntsb/NYC08LA086 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Maintenance](https://openairdocs.org/ntsb-findings/02062000): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28R-200, 2 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md?model=7102811), [All aircraft, 143 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md) - [Terrain](https://openairdocs.org/ntsb-findings/03021000): Environmental issues › Physical environment · Contributed to outcome (probable cause); cases with it: [Piper PA-28R-200, 1 case](https://openairdocs.org/ntsb-findings/03021000/cases.md?model=7102811), [All aircraft, 267 cases](https://openairdocs.org/ntsb-findings/03021000/cases.md) - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-28R-200, 4 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=7102811), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Fatigue/wear/corrosion (probable cause); cases with it: [Piper PA-28R-200, 4 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=7102811), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Piper PA-28R-200, 7 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=7102811), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-climb to cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Piper PA-28R-200, 6 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=7102811), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Enroute-climb to cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Piper PA-28R-200, 32 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102811), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28R-200, 30 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102811), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Piper PA-28R-200, 2 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=7102811), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## 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](https://openairdocs.org/deregistered/N1939T-2008-06-11), registration cancelled 2008-06-11, S/N 28R-7135137, built 1971 (OpenAirDocs) - Reported make and model: PIPER PA-28-R200 - 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-7135137 - Airframe hours: 3329 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 37; injuries: minor; 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 (OpenAirDocs). - [Accident 20080125831359A](https://openairdocs.org/incident/20080125831359A), Jan 25, 2008: Piper PA28R200, York, SC, Substantial damage. (-23) The aircraft departed rockhill, SC on a VFR flight to ashville, NC. Twenty minutes into the flight, the pilot stated that he heard a "clunk" and that the… 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.