Pilot Debrief

PIPER PA-28R-200 near Hilliard, FL — 2009-04-23

Final reportERA09LA261
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Date
2009-04-23
Location
Hilliard, FL, USA
Airport
01J
Aircraft
PIPER PA-28R-200
Registration
N2938R
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Climb

Probable cause

A total loss of engine power due to the fatigue failure of the No. 3 cylinder attachment stud as a result of insufficient torque during installation. Contributing to the accident was the pilot’s operation of the airplane with a known mechanical deficiency.

NTSB narrative

Approximately 2 hours into the cross-country flight the pilot heard a loud noise from the engine compartment and the engine subsequently failed. The pilot performed a forced landing in a field and the empennage struck a tree, resulting in substantial airframe damage. Examination of the engine revealed that the No. 3 cylinder partially separated in flight, resulting in the engine failure. An engine cylinder attachment stud and nut were found at the run-up pad at the departure airport. Examination of the stud revealed evidence of fatigue cracking, which was indicative of an under torque condition. Other cylinder attachment nuts on the engine showed evidence of under torquing. The pilot had recently purchased the airplane and the seller reported that an oil leak was noted during the "pre-buy" inspection. The mechanic who inspected the airplane at the pre-buy reported that two cylinders were leaking oil. The seller installed the cylinders as part of a major overhaul that occurred approximately 131 hours prior to the accident. The pilot did not have maintenance performed to address the cylinder oil leaks prior to the accident.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot could have addressed the oil leak before the flight.

NTSB coding

Evidence available

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

Docket documents13

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