Pilot Debrief

PIPER PA38 - 112 near Millbury, OH — 2015-07-25

Final reportCEN15LA318
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Date
2015-07-25
Location
Millbury, OH, USA
Airport
TDZ
Aircraft
PIPER PA38 - 112
Registration
C-GTAO
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Initial climb

Probable cause

A loss of engine power due to three of the engine valve adjustment mechanisms backing out, which resulted from improper maintenance.

NTSB narrative

Shortly after takeoff, the pilot declared a "mayday" and reported to air traffic control that he needed to return to the airport. The airplane crashed in an open field about ½ mile from the airport. The pilot initially survived the accident but later died from his injuries. A postaccident examination of the engine revealed the valve adjustment mechanisms (jam nut and screw) on two of the intake valves and on one of the exhaust valves were backed off. The valve spring retainer on one of the intake valves was broken, and two of the cylinder head gaskets were compromised. The spark plugs were fouled. Given the postaccident condition of the engine, the pilot most likely was returning to the airport due to a loss of engine power. Maintenance records show the engine had an annual inspection about 25 flight hours before the accident. The condition of the valve adjustment mechanisms suggests that either the tappet adjustment was not checked, as recommended by the manufacturer, or the torque on the jam nuts was incorrect.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot could have aborted takeoff after engine issues were detected.

NTSB coding

Evidence available

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

Docket documents6

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