Pilot Debrief

PIPER PA-28R-200 near Wappinger, NY — 2009-11-22

Final reportERA10FA074
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Date
2009-11-22
Location
Wappinger, NY, USA
Airport
POU
Aircraft
PIPER PA-28R-200
Registration
N345AT
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Climb

Probable cause

A total loss of engine power due to a delamination of the No. 3 connecting rod bearing. Contributing to the accident was the inadequate maintenance inspection of the engine oil system.

Contributing factors

Contributing to the accident was the inadequate maintenance inspection of the engine oil system.

NTSB narrative

About 10 minutes after takeoff, the pilot advised air traffic control that he was experiencing an oil problem and subsequently maneuvered the airplane for an emergency landing at an airport about 7 nautical miles away. The engine ceased producing power shortly thereafter and the airplane subsequently impacted trees and terrain during a forced landing. Metallurgical examination of the engine components attributed the loss of engine power to the failure of the No. 3 connecting rod bearing. Measurement of journal diameters were consistent with the correct bearings having been installed and a lack of substantial debris in the No. 4 bearing suggested that oil contamination was not contributory. The deformation and color of the recovered No. 3 connecting rod bearing pieces were consistent with the backing of the bearing extruding out of the connecting rod journal interface while under lubrication, and was consistent with failure due to delamination of the bearing. Damage to the bearing from continued operation after it failed prevented a conclusive determination as to whether the bearing had been damaged by a brief period of reduced oil pressure or wear over time. The engine was overhauled about 18 years and 1,700 flight hours prior to the accident. Maintenance records for that period showed inconsistent documentation of manufacturer-recommended oil filter element inspections following engine oil changes, with no documented oil suction screen or filter inspections in the 4 years preceding the accident.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have performed better engine monitoring and maintenance.

NTSB coding

Evidence available

  • FDR / data
  • ADS-B / radar
  • Photos
  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10

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