Pilot Debrief

Piper PA32 near Bartow, FL — 2018-09-28

Final reportERA18LA265
Sign in to save
Date
2018-09-28
Location
Bartow, FL, USA
Aircraft
Piper PA32
Registration
N4592X
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Cruise

Probable cause

A total loss of engine power after the separation of the No. 3 cylinder from the crankcase due to improper maintenance.

NTSB narrative

The private pilot reported that during cruise flight, the engine began to run roughly. The No. 3 cylinder then separated from the airplane; the engine lost all power, and oil began to cover the windshield. The pilot flew via instruments and landed in a marsh; the right wing of the airplane separated after contacting a tree. Postaccident engine examination revealed impact marks on the engine crankcase where the No. 3 cylinder would have been secured. The marks were consistent with the cylinder impacting the case multiple times. The examination also revealed that several of the nuts on other cylinders were well below the required 50 ft-lbs of torque. The engine's most recent overhaul was completed about 12 years before the accident, and the engine had accrued about 366 hours since that overhaul; there was no record of cylinder removal or replacement since the engine overhaul. It is likely that undertorqued cylinder nuts allowed the cylinder to come loose and separate from the engine. The investigation could not determine if the undertorqued condition of the cylinder nuts was the result of an improper overhaul or possible improper undocumented maintenance after the overhaul.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have conducted a precautionary landing before engine failure escalated.

NTSB coding

Evidence available

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

Docket documents5

Related mishaps