Aviation Accident Summaries

Aviation Accident Summary CEN13LA280

Galena, KS, USA

Aircraft #1

N57719

PIPER PA-36-285

Analysis

Shortly after takeoff, the pilot noticed a decrease in the engine's oil pressure. The engine then sustained a total loss of power, and the airplane collided with terrain during the forced landing. An examination of the engine revealed that the No. 2 piston had failed. In addition, each of the spark plugs had two washers installed, instead of one, and the oil filter contained many metal particles. The two washers likely altered the detonation characteristics of the pistons, causing them to overheat. As the No. 2 piston degraded, metal particles collected in the oil filter. Maintenance records indicate that the engine was overdue for a recommended oil change; the deteriorating piston would likely have been detected during an oil change. The mechanic who performed the last annual inspection was not aware that additional spark plug washers had been installed on the engine.

Factual Information

On May 14, 2013, about 1050 central daylight time, a Piper PA-36-285 airplane, N57719, conducted a forced landing near Galena, Kansas. The commercial pilot sustained minor injuries. The airplane sustained substantial damage to the fuselage. The airplane was registered to and operated by Four States Sky Ag Inc. under the provisions of 14 Code of Federal Regulations Part 137 as an agricultural application flight. Visual meteorological conditions prevailed for the flight, which operated without a flight plan. The local flight departed the Swalley Airpark (78KS), Baxter Springs, Kansas, about 1045. According to a statement provided by the pilot to the responding Federal Aviation Administration (FAA) inspectors, the airplane had departed 78KS and he had just began to level off when he noticed a decrease in oil pressure. The engine experienced a total loss of power before the pilot could set up for a forced landing. The airplane collided with terrain in an open field. An examination of the engine conducted by the FAA inspectors revealed that the number 2 cylinder piston had failed. A large amount of aluminum particles were observed in the oil and the oil filter. Each spark plug had two spark plug washers. Maintenance records determined that the recommended oil change time had been exceeded. The mechanic that performed the last annual inspection stated he had not installed the extra spark plug washers and was not aware of their presence on the engine. It could not be determined who installed the additional spark plug washers.

Probable Cause and Findings

The loss of engine power due to improper maintenance by an unknown individual that led to the degradation and deterioration of the No. 2 piston, which was undetected because of overdue maintenance.

 

Source: NTSB Aviation Accident Database

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