SEA05LA170

NTSB accident investigation · Piper PA-24-250 · Challis, ID · August 13, 2005

Accident · Serious injuriesLimited investigationFinal report
Date
August 13, 2005, 10:30 local (16:30 UTC)
Place
Challis, ID
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N6677PPiper PA-24-250
Weather
Visual (VMC) · Day
Status
Completed · report March 28, 2006
Report
Approved by Office Director
Parties
FAA FSDO, Textron Lycoming, The New Piper Aircraft Company
FAA report
20050813018279A
Case key
62215

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

The installation of an improper oil gasket by maintenance personnel, which resulted in a loss of engine oil and subsequent loss of engine power during the emergency descent.

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.

Airframe/component/system failure/malfunctionClimb - to cruise
Maintenance,overhaul - improperOther maintenance personnelCause
Lubricating system,oil gasket - incorrectCause
Loss of engine power(partial) - mech failure/malfLanding
Lubricating system,oil gasket - failureCause
Fluid,oil - loss,totalCause
Forced landingEmergency descent/landing
Hard landingEmergency landing
Terrain condition - ground

Analysis

The pilot reported that shortly after takeoff, the propeller RPM became erratic and uncontrollable and he elected to return to the airport. He reported that during the descent, the airplane developed a rough running engine and eventually lost power resulting in an off airport landing. Preliminary external examination of the assembly revealed a large hole in the engines crankcase, adjacent to the number four cylinder assembly. The number four piston rod was fractured and extensive heat distress, deformation and discoloration was noted to both the number three and number four piston assemblies. A representative from Textron Lycoming reported that this type of damage is indicative of oil depravation. Further examination of the engine assembly revealed that the hydraulic pump adapter pad cover gasket was protruding from between the accessory mounting pad and its associated cover. A section of the gasket separated and was displaced from its installed position. The FAA Airworthiness Inspector overseeing the examination reported that the installed gasket was intended to be used in conjunction with a hydraulic pump, if applicable, however, this particular engine configuration does not utilize a hydraulic pump, and therefore a hydraulic pump adapter pad gasket should have been installed. Personnel at the Challis airport reported that a large puddle of oil was found in the run-up area following the airplane's pre takeoff run-up and departure.

Factual narrative

On August 13, 2005, about 1030 mountain daylight time, a Piper PA-24-250 Comanche, N6677P, sustained substantial damage following a loss of engine power and off airport forced landing near the Challis Airport (LLJ), Challis, Idaho. The airplane is owned by the pilot and was being operated as a visual flight rules (VFR) personal/pleasure flight under the provisions of 14, CFR Part 91, when the accident occurred. The private pilot and passenger received serious injuries. Visual meteorological conditions prevailed, and no flight plan was filed for the flight that originated at Challis approximately 3 minutes prior to the accident. The pilot's intended destination was Mackay, Idaho.

During a telephone conversation with the National Transportation Safety Board IIC on August 15, the pilot reported that shortly after takeoff from runway 34, the propeller RPM became erratic and uncontrollable and he elected to return to Challis. He reported that during the descent into Challis the airplane developed a rough running engine and eventually lost power. The pilot stated that he landed in a hay field, short of runway (16), resulting in substantial damage.

Personnel at the Challis airport reported that a large puddle of oil was found in the run-up area following the airplane's pre takeoff run-up and departure.

The airplane was equipped with a Lycoming O-540-A1C5 engine. Examination of the engine's maintenance records revealed that the engine had been overhauled and inspected on July 13, 2004, subsequent to a "prop strike." The records indicated that the "tach time" at overhaul was 255.6 hours, approximately 35.2 hours prior to the accident. Additional maintenance records for this accident can be found in the public docket.

On August 25, representatives from the Federal Aviation Administrations Boise, Idaho, Flight Standards District Office, (FSDO), Textron Lycoming and The New Piper Aircraft Company performed an engine examination and teardown.

Preliminary external examination of the assembly revealed a large hole in the engines crankcase, adjacent to the number four cylinder assembly. The number four piston rod was fractured and extensive heat distress, deformation and discoloration was noted to both the number three and number four piston assemblies. The representative from Textron Lycoming reported that this type of damage is indicative of oil depravation.

Further examination of the engine assembly revealed that the hydraulic pump adapter pad cover gasket was protruding from between the accessory mounting pad and its associated cover (part number 89106). A section of the gasket (part number 68315) separated and was displaced from its installed position.

The FAA Airworthiness Inspector overseeing the examination reported that the installed gasket (Part number 68315) was intended to be used in conjunction with a hydraulic pump, if applicable, however, this particular engine configuration does not utilize a hydraulic pump, and therefore a hydraulic pump adapter pad gasket (part number 69551) should have been installed.

The Lycoming O-540-A series Parts Catalog illustrates the use of gasket number 69551 when utilizing the hydraulic pump adapter pad cover.

Aircraft

Registration
N6677P
Reported as
Piper PA-24-250
Category
Airplane
Serial number
24-1801
Airframe hours
4,571
Engine
Lycoming O-540, 250 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Christopher James Trust
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 1, 2004 · 35 hours before
Departed
KLLJ · Challis, ID
Destination
U62 · Mackay, ID
Airport
U15 · Challis, runway 34, 4,600 × 60 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
59
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
February 1, 2005
Seat
Left
Flight hours
328 total · 62 in this make and model · 267 as pilot in command · 6 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
30° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
61 °F, dew point 39 °F
Altimeter
30.12 inHg
Observed at
KLLJ, 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.