Pilot Debrief

Piper PA28 near Boca Raton, FL — 2019-09-11

Final reportCEN19LA317
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Date
2019-09-11
Location
Boca Raton, FL, USA
Airport
BCT
Aircraft
Piper PA28
Registration
N2890T
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Initial climb

Probable cause

The total loss of engine power for reasons that could not be determined based on available evidence and the pilot’s decision to take off without fully troubleshooting the partial loss of engine power that occurred during the previous flight.

NTSB narrative

Following a partial loss of engine power after takeoff, the pilot returned to the airport and performed a visual inspection and engine test run with a mechanic, which revealed no anomalies. The pilot then chose to perform another flight without identifying the cause of the loss of engine power and the mechanic agreed to accompany him. As the airplane climbed through 400 to 500 ft above ground level after takeoff, the engine ran rough, and the pilot started a turn back to the airport. The engine subsequently lost total power and the airplane impacted terrain and obstacles. The airplane was equipped with an engine monitor that captured exhaust gas temperatures (EGT), cylinder head temperatures (CHT), and turbine inlet temperature (TIT). TIT is the direct measurement of the temperature of combined exhaust from all cylinders immediately before it enters the turbocharger, but the measurement itself is not used in the normal operation of the turbocharger. The data showed a rapid drop in TIT about 45 seconds before changes in the CHT and EGT associated with both loss of power events on the day of the accident. The data also recorded three other sessions in which the TIT dropped similarly, but there were no associated changes to EGT or CHT values to indicate a loss of engine power on those occasions. No evidence was found to indicate a loss of engine power resulted directly from the changes in TIT or what caused those changes. Examination of the engine revealed a hole in the turbocharger’s automatic wastegate controller diaphragm, which would result in the wastegate failing toward the closed position. The closed wastegate would increase manifold pressure and decrease the efficiency of the turbocharger at higher altitudes; however, a closed wastegate would not result in a total loss of engine power. The reason for the loss of engine power could not be determined based on available evidence.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Performing maintenance after initial engine roughness could have prevented the accident.

NTSB coding

Evidence available

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

Docket documents18

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