Pilot Debrief

DIAMOND DA40 near Norfolk, VA — 2019-09-15

Final reportERA19LA272
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Date
2019-09-15
Location
Norfolk, VA, USA
Airport
CPK
Aircraft
DIAMOND DA40
Registration
N292RA
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Takeoff roll

Probable cause

A partial loss of engine power due to the mechanic's failure to properly tighten the two clamps securing the flexible coupling from the intercooler to the induction inlet.

NTSB narrative

The pilot said that, shortly after takeoff, he heard a noise from under the engine cowling followed by a partial loss of engine power. The pilot was unable to maintain altitude and made a forced landing to a field, which resulted in substantial damage to the fuselage. Data downloaded from the airplane's electronic engine control unit was consistent with an uncommanded decrease in induction air boost pressure on takeoff. Postaccident examination of the engine revealed that the flexible induction coupling between the intercooler and the engine induction inlet had backed off. The two clamps that secured the flexible coupling to the induction inlet were intact and safety wired. However, the two clamps were loose, and the induction tube could be inserted into the coupling without loosening the clamps. A review of maintenance records revealed that the flexible induction coupling and clamps had been removed and replaced at the last 100-hour inspection about 15 flight hours before the accident. Because the two clamps that secured the coupling from the intercooler to the induction inlet were recently replaced, it is likely that the mechanic who installed the clamps did not properly tighten them, and they loosened in flight, leading to the induction inlet backing off and resulting in a loss of engine power.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have aborted takeoff after hearing noise from engine.

NTSB coding

Evidence available

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

Docket documents4

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