# NTSB NYC91FA178: Piper PA-32RT-300T, N36272, Yarmouth, MA, July 13, 1991 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 12, 1991, 20:02 local (Jul 13, 1991, 00:02 UTC) - Place: Yarmouth, MA - Location: 41.6757° N, 70.2629° W: Placed by OpenAirDocs from NTSB’s distance and direction from CAPE COD GATEWAY (HYA), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=41.6757&lon=-70.2629&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report April 14, 1992 - Report: Approved by Office Director - Safety recommendations: Yes - NTSB case key (mKey): 36800 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC91FA178 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/36800/pdf - Page: https://openairdocs.org/ntsb/NYC91FA178 ## Probable cause THE FAILURE OF THE NUMBER ONE CYLINDER FUEL INJECTOR LINE DUE TO FATIGUE CRACKING INDUCED BY CORROSION AND PROPAGATED BY CYCLIC LOADING WHICH RESULTED IN A TOTAL LOSS OF ENGINE POWER. THE CORROSION WAS DUE TO THE MANUFACTURER'S PROCESS OF BRAZING THE METAL JOINT, AND THE CYCLIC LOADING WAS DUE TO THE ABSENCE OF A CLAMP TO MINIMIZE THE EFFECT OF VIBRATION. A CONTIBUTING FACTOR WAS THE LACK OF SUITABLE TERRAIN DURING THE SUBSEQUENT FORCED LANDING. ## 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, approach - vfr pattern - base leg/base to final - fuel system,line - corroded (cause) - material inadequate, manufacturer (cause) - fuel system,line - vibration (cause) - maintenance,installation - improper, other maintenance personnel (cause) - fuel system,line - fatigue (cause) - fuel system,line - separation (cause) - fluid,fuel - starvation (cause) - Forced landing, approach - vfr pattern - base leg/base to final - On ground/water collision with object, approach - vfr pattern - base leg/base to final - terrain condition - high obstruction(s) (contributing factor) - object - tree(s) ## Analysis AFTER RECEIVING CLEARANCE TO LAND, THE PILOT CALLED THAT HE WAS IN TROUBLE AND WAS GOING DOWN. WITNESSES SAW THE AIRPLANE AT A LOW ALTITUDE, AND HEARD THE ENGINE SPUTTERING AND THEN QUIT. THE LEFT WING STRUCK A TREE; THE AIRPLANE IMPACTED THE GROUND AND WAS COMPLETELY DESTROYED BY THE POST CRASH FIRE. ENGINE TEARDOWN REVEALED THAT THE CYLINDER #1 FUEL INJECTOR LINE HAD FAILED AT THE OUTER DIAMETER (OD) SURFACE AT THE MANIFOLD END NEAR THE B-NUT FITTING. METALLURGICAL EXAMINATION INDICATED THAT THE SEPARATION WAS DUE TO FATIGUE CRACKING THAT ORIGINATED AT THE OD SURFACE OF THE TUBE AT THE EDGE WITH THE BRAZED FILLER METAL. INTERGRANULAR CORROSION WAS OBSERVED AT THE FRACTURE ORIGIN WHICH OCCURRED DURING MANUFACTURE, WHEN THE LINE WAS SENSITIZED NEAR THE BRAZING JOINT. THERE WAS NO EVIDENCE OF CLAMPING OF THE TUBE AT MIDPOINT PER THE ENGINEERING DRAWING. ## Aircraft - Registration: [N36272](https://openairdocs.org/deregistered/N36272-1991-12-16), registration cancelled 1991-12-16, S/N 32R7887030 (OpenAirDocs) - Reported make and model: PIPER PA-32RT-300T (PA-32RT-30) - Registry model: [Piper PA-32RT-300T](https://openairdocs.org/model/piper-pa-32rt-300t) (registry code 7103216) (OpenAirDocs) - Category: Airplane - Serial number: 32R-7887030 - Engines: LYCOMING TIO-540-S1AD 300 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: John & Mary Santoin - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, May 4, 1991, 20 hours before - Departed: MUY, MARTHAS VINEYAR, MA - Destination: HYANNIS, MA - Airport: HYA, Barnstable Muni, runway 24, 5,430 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 1,260 total ## Weather - Conditions: Visual (VMC), Dusk - Wind: 200° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 57 °F - Altimeter: 29.00 inHg - Observed at: HYA, 1 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 19910712027389A](https://openairdocs.org/incident/19910712027389A), Jul 12, 1991: Piper PA32RT300T, Hyannis, MA, Destroyed, 2 fatal. Fuel injector line NR1 cylinder broke. Installed minus clamps. Engine quit on base leg. Crashed into trees. Burned. ## Other investigations on N36272 (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 UNK64X1299](https://openairdocs.org/ntsb/UNK64X1299), Apr 13, 1964: Piper PA22 (N36272), Bennington, VT, 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.