SEA03LA183

NTSB accident investigation · Piper PA-28-140 · Homedale, ID · September 3, 2003

Accident · Serious injuriesLimited investigationFinal report
Date
September 3, 2003, 09:00 local (15:00 UTC)
Place
Homedale, ID
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N15367Piper PA-28-140
Weather
Visual (VMC) · Day
Status
Completed · report June 2, 2004
Report
Approved by Office Director
Parties
FAA-FSDO, Lycoming, The New Piper Aircraft, Inc
FAA report
20030903021989A
Case key
57878

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 during descent due to a failed cylinder head.

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/malfDescent
Engine assembly,cylinder - fatigueCause
Forced landingDescent - emergency
Hard landingEmergency descent/landing

Analysis

The pilot reported that the airplane's engine developed an uncharacteristic vibration while in a cruise flight configuration. The pilot stated that he diverted to a nearby airport and shortly after entering a downwind for the intended runway, the engine "quit." The pilot stated he turned directly toward runway 31 after the engine failure. Shortly after completing the turn to final, the pilot landed on the intended runway. The pilot reported that the airplane "...hit very hard." It was later discovered that the pilot's seat collapsed as a result of the hard landing. Examination of the aircraft's engine revealed a fracture in the number four cylinder head. The full thickness fracture emanated from the top sparkplug hole and traveled the circumference of the cylinder, terminating at the bottom sparkplug hole. The metallurgical examination of the cylinder revealed that the cylinder head fractured due to fatigue. The exam report indicated that multiple fatigue failure initiation sites were observed, most notably a series of cracks that initiated at each of the two sparkplug holes. Maintenance records indicated that the failed cylinder was repaired due to valve pitting. Following the repairs, the cylinder was returned to service. At the time of the repairs, the engines total time was 6,689 hours; 726 hours since major overhaul. The cylinder total time since manufacture could not be determined. At the time of the accident, the engine total time was approximately 7,260 hours; 1,319 hours since major overhaul.

Factual narrative

On September 3, 2003, about 0900 mountain daylight time, a Piper PA-28-140, N15367, sustained substantial damage following a loss of engine power and subsequent hard landing at the Homedale Municipal Airport (S66), Homedale, Idaho. The airplane is owned by the pilot and was being operated as a visual flight rules (VFR) cross-country flight under the provisions of Title 14, CFR Part 91, when the accident occurred. The private pilot was seriously injured and his passenger received minor injuries. Visual meteorological conditions prevailed, and no flight plan was filed. The flight originated from Ontario, Oregon, approximately one hour prior to the accident.

The pilot reported that the airplane's engine developed an uncharacteristic vibration while in a cruise flight configuration. The pilot stated that he diverted to a nearby airport and shortly after entering a downwind for the intended runway, the engine "quit." The pilot stated he turned directly toward runway 31 after the engine failure. Shortly after completing the turn to final, the pilot landed on the intended runway. The pilot reported that the airplane "...hit very hard." It was later discovered that the pilot's seat collapsed as a result of the hard landing.

On September 17, 2003, investigators from the National Transportation Safety Board, Piper Aircraft and Lycoming accessed the aircraft. Examination of the aircraft's engine, a Lycoming O-320 E2A, revealed a fracture in the number four cylinder head. The full thickness fracture emanated from the top sparkplug hole and traveled the circumference of the cylinder, terminating at the bottom sparkplug hole.

Subsequent to the engine examination, the fractured cylinder was transported to Northwest Laboratories of Seattle, Inc, for further metallurgical examination.

The metallurgical examination of the cylinder revealed that the cylinder head fractured due to fatigue. The exam report (attached) indicated that multiple fatigue failure initiation sites were observed, most notably a series of cracks that initiated at each of the two sparkplug holes. The report indicated the cracks propagated through the thickness of the cylinder wall and formed a single crack front.

Maintenance records indicated that the failed cylinder (cylinder number four) was removed and repaired due to valve "pitting" in June of 1992. Following the repairs, the cylinder was returned to service. At the time of the repairs, the engines total time was 6,689 hours; 726 hours since major overhaul. The cylinder total time since manufacture could not be determined.

According to maintenance records for the engine, the last annual inspection was completed on November 14, 2002. The maintenance logbook entry corresponding to the annual inspection indicated that the engine total time was 7,260 hours; 1,319 hours since major overhaul. The engine had accumulated approximately 36 hours from the time of the annual inspection to the time of the accident.

Aircraft

Registration
N15367
Reported as
Piper PA-28-140
Category
Airplane
Serial number
28-7325048
Airframe hours
3,537
Engine
Lycoming O-320, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Ronald E. LaBrousse
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 14, 2002 · 36 hours before
Departed
ONO · Ontario, OR
Destination
S66 · Homedale
Flight plan
Unknown
Airport
S66 · Homedale Muni, runway 31, 2,900 × 50 ft, asphalt

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
49
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Last flight review
October 25, 2001
Seat
Left
Flight hours
350 total · 190 in this make and model · 282 as pilot in command · 23 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Lowest ceiling
None

FAA reports on this event · 1

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