WPR14LA249

NTSB accident investigation · Piper PA 28-180 · Quincy, CA · June 15, 2014

Accident · No injuriesLimited investigationFinal report
Date
June 15, 2014, 11:10 local (18:10 UTC)
Place
Quincy, CA
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N4931LPiper PA 28-180
Defining event
Initial climb: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report August 11, 2015
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20140615010549A
Case key
89452

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 partial loss of engine power during takeoff due to the separation of the exhaust baffling, which resulted in a partial blockage of airflow to the engine. Contributing to the accident was maintenance personnel’s inadequate inspection of the exhaust system during the airplane’s most recent maintenance.

Findings · 3

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.

Engine exhaustAircraft › Aircraft power plant · FailurePiper PA-28-180: 2 casesAll aircraft: 56 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelPiper PA-28-180: 6 casesAll aircraft: 320 casesProbable cause
Engine exhaustAircraft › Aircraft power plant · Not serviced/maintainedPiper PA-28-180: 2 casesAll aircraft: 56 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

The pilot reported that, shortly after takeoff, the airplane would not climb; therefore, he chose to make a precautionary landing onto a nearby field. During the final approach, the stabilator impacted a fence post, and the pilot subsequently landed the airplane uneventfully. During a postaccident examination of the exhaust system, the baffles within the muffler assembly were found partially separated and blocking the exhaust ducts, which would have restricted the airflow in the ducts and resulted in a loss of engine power when the airplane reached a higher engine rpm setting during takeoff. No additional mechanical anomalies were observed that would have precluded normal operation. The airplane manufacturer's service manual states, in part, "a very thorough inspection of the entire exhaust system, including the…muffler and muffler baffles, stacks, and all exhaust connections and welds must be accomplished at each 100-hour inspection. The possibility of exhaust system failure increases with use." The airplane's most recent annual inspection, which should have included the items from the 100-hour inspection, occurred about 3 flight hours before the accident. Maintenance records indicated that maintenance personnel inspected the exterior of the muffler system; however, the records did not indicate that maintenance personnel performed the airplane manufacturer-recommended exhaust system inspection.

Factual narrative

On June 15, 2014, about 1110 Pacific daylight time, a Piper 28-180, N4931L, experienced a partial loss of engine power after takeoff from Gansner Field Airport (2O1), Quincy, California. The certified flight instructor and three passengers were uninjured, and the airplane sustained substantial damage. The airplane was registered to a private party and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight, and no flight plan was filed. The pilot reported that he took off with 10 degrees of flaps. During the initial climb, the pilot retracted the flaps and the airplane started to lose altitude. He extended flaps again, and the airplane continued to climb, but once he retracted them a second time the airplane descended. The pilot realized the airplane would not climb and elected to make a precautionary landing onto a nearby field. During final approach, the stabilator impacted a fence post, before landing uneventfully. A postaccident examination by a Federal Aviation Administration inspector revealed compression on all four cylinders. The intake system was examined and revealed no restrictions or damaged components. The carburetor float bowl was removed and the fuel inside appeared uncontaminated. A light was shined in the forward exhaust pipe and it appeared to be partially blocked. Examination of the aft exhaust pipe revealed it was also partially blocked. Both the forward and aft mufflers were removed; in both cases, the muffler baffling separated from its mount and covered the exhaust port outlet. Review of the engine maintenance logbook records revealed that the most recent annual inspection was completed on May 15, 2014, at an airframe total time of 4,016.55 hours. The pilot reported that, at the time of the accident, the airplane had accumulated about 3 hours of operation since the annual inspection. The front muffler time in service could not be determined. The aft muffler time in service was 1,359 hours. During the inspection, an exterior inspection of the muffler system was performed; however, the exhaust system inspection recommended by Piper was not performed. The Piper Cherokee Service Manual states in part "…a very thorough inspection of the entire exhaust system including exhaust heater shroud assembly, muffler and muffler baffles, stacks, and all exhaust connections and welds must be accomplished at each 100-hour inspection. The possibility of exhaust system failure increases with use. It is recommended that the system be checked more carefully as the number of hours increase, therefore inspection at the 700 hour period, that the exhaust system has been in use would be more critical than ones in the 100 hour period. The system should also be checked carefully before winter operation when the cabin heat will be in use. NOTE: Piper recommends that all PA-28 airplanes be fitted with a new muffler at or near the 1,000 hourperiod of which the muffler has been used."

Aircraft

Registration
N4931L
Reported as
Piper PA 28-180
Category
Airplane
Serial number
28-4299
Built
1967
Airframe hours
4,016
Engine
Lycoming IO-360 SERIES, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Parker Larry
Registered owner
Parker Larry
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 16, 2014 · 3 hours before
Departed
2O1 · Quincy, CA
Destination
2O1 · Quincy, CA
Airport
2O1 · Ganser Field Airport, runway 7, 4,105 × 60 ft, grass/turf

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
68
Injuries
None
Certificate
Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
January 13, 2014
Seat
Left
Restraint
Lap only
Flight hours
2,370 total · 1,065 in this make and model · 2,173 as pilot in command · 17 in the last 90 days · 14 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 5 knots
Visibility
80 statute miles
Lowest ceiling
None
Temperature
77 °F, dew point 41 °F
Altimeter
29.76 inHg
Observed at
CIC, 42 nm away

Docket · 4

The files NTSB released with the investigation on June 11, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.7 MB in all.

FAA reports on this event · 1

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