Pilot Debrief

Piper PA28 near McMinnville, TN — 2020-09-08

Final reportERA20LA309
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Date
2020-09-08
Location
McMinnville, TN, USA
Airport
RNC
Aircraft
Piper PA28
Registration
N4166Z
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Initial climb

Probable cause

A total loss of engine power due to a fatigue failure in a cylinder, and the pilot’s subsequent failure to maintain airspeed and her exceedance of the airplane’s critical angle-of-attack while maneuvering at low altitude.

NTSB narrative

During initial climb, below 500 ft above ground level, the engine experienced a total loss of power due to a separated cylinder head. The pilot initiated a right turn (based on the orientation of the wreckage) and the airplane stalled and spun flat into a field. Metallurgical examination of the cylinder revealed fatigue cracking, which was observed around approximately 180° of the cylinder circumference. The fatigue cracking emanated from the vertical stiffener on the front of the cylinder between the third and fourth fins. The fatigue cracking appeared to initiate at the start of the fillet between the vertical stiffener and the circumferential outer wall of the cylinder. The remainder of the fracture surface was consistent with overstress. The cylinder was installed new when the engine was overhauled about 19 months prior to the accident. The engine had accrued about 671 hours since overhaul.

Analysis

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

NTSB coding

Evidence available

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

Docket documents12

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