Pilot Debrief

PIPER PA-36-285 near Galena, KS — 2013-05-14

Final reportCEN13LA280
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Date
2013-05-14
Location
Galena, KS, USA
Aircraft
PIPER PA-36-285
Registration
N57719
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Initial climb

Probable cause

The loss of engine power due to improper maintenance by an unknown individual that led to the degradation and deterioration of the No. 2 piston, which was undetected because of overdue maintenance.

NTSB narrative

Shortly after takeoff, the pilot noticed a decrease in the engine's oil pressure. The engine then sustained a total loss of power, and the airplane collided with terrain during the forced landing. An examination of the engine revealed that the No. 2 piston had failed. In addition, each of the spark plugs had two washers installed, instead of one, and the oil filter contained many metal particles. The two washers likely altered the detonation characteristics of the pistons, causing them to overheat. As the No. 2 piston degraded, metal particles collected in the oil filter. Maintenance records indicate that the engine was overdue for a recommended oil change; the deteriorating piston would likely have been detected during an oil change. The mechanic who performed the last annual inspection was not aware that additional spark plug washers had been installed on the engine.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Perform timely engine maintenance to prevent oil pressure loss.

NTSB coding

Evidence available

  • Photos
  • 2 docket documents
View NTSB final reportView NTSB docket

Docket documents2

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