Pilot Debrief

PIPER PA-32-260 near Los Angeles, CA — 2021-02-19

Final reportWPR21FA114
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Date
2021-02-19
Location
Los Angeles, CA, USA
Aircraft
PIPER PA-32-260
Registration
N57014
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Climb

Probable cause

The total loss of engine power due to the failure of the No. 6 exhaust valve for reasons that could not be determined based on available evidence.

NTSB narrative

Shortly after takeoff, the pilot reported to air traffic control that the airplane was experiencing engine problems and he was going to make an off-airport landing. The airplane contacted a semi-truck and a concrete barrier during the landing in a shipping harbor. Postaccident examination of the engine revealed that the No. 6 cylinder exhaust valve head was separated from the stem. A fatigue crack was found in the exhaust valve upper spring seat of the No. 6 cylinder assembly that likely led to the release of the exhaust valve. The crack formed at the base of the cup that housed the valve stem keys, causing a portion of the flange that supported the keys to separate. This could have allowed the exhaust valve to drop into the cylinder, impacting the piston, the cylinder head, and the exposed end of the valve guide before being sheared through the stem near the stem-to-fillet transition. The findings suggest that the No. 6 exhaust valve may have been floating, which would have removed the compressive load on the keys and allowed them to move and rub against the support flange and sidewall of the spring seat cup. The compression test of the exhaust valve springs indicated that they did not pass, suggesting that a floating valve is a possibility. However, the No. 5 exhaust valve springs also did not pass, and similar wear features around the key cup were not observed in that instance. Because the keys and valve stem were not found (likely destroyed during the continual operation with the failed valve), it could not be determine if there was some issue with either component that could have contributed to the failure.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have aborted the flight after first signs of engine problems.

NTSB coding

Evidence available

  • ADS-B / radar
  • 12 docket documents
View NTSB final reportView NTSB docket

Docket documents12

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