Aviation Accident Summaries

Aviation Accident Summary ERA18LA265

Bartow, FL, USA

Aircraft #1

N4592X

Piper PA32

Analysis

The private pilot reported that during cruise flight, the engine began to run roughly. The No. 3 cylinder then separated from the airplane; the engine lost all power, and oil began to cover the windshield. The pilot flew via instruments and landed in a marsh; the right wing of the airplane separated after contacting a tree. Postaccident engine examination revealed impact marks on the engine crankcase where the No. 3 cylinder would have been secured. The marks were consistent with the cylinder impacting the case multiple times. The examination also revealed that several of the nuts on other cylinders were well below the required 50 ft-lbs of torque. The engine's most recent overhaul was completed about 12 years before the accident, and the engine had accrued about 366 hours since that overhaul; there was no record of cylinder removal or replacement since the engine overhaul. It is likely that undertorqued cylinder nuts allowed the cylinder to come loose and separate from the engine. The investigation could not determine if the undertorqued condition of the cylinder nuts was the result of an improper overhaul or possible improper undocumented maintenance after the overhaul.

Factual Information

On September 28, 2018, about 1325 eastern daylight time, a Piper PA-32-300, N4592X, operated by the private pilot, was substantially damaged during a forced landing to a marsh, following a total loss of engine power during cruise flight near Bartow, Florida. The private pilot and passenger sustained minor injuries. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for planned flight to Tampa Executive Airport (VDF), Tampa, Florida. The flight originated from Boca Raton Airport (BCT), Boca Raton, Florida, about 1230.The pilot reported that during cruise flight, the engine began to run rough. He notified air traffic control (ATC) and declared an emergency. Shortly thereafter, the engine cowling separated and the pilot observed that a cylinder had separated as oil began to cover the windscreen. Although ATC provided vectors to the nearest airport, the pilot could not see due to the oil, and flew via the instruments to the ground. Examination of the accident site by a Federal Aviation Administration inspector revealed that during the landing in a marsh, the right wing contacted a tree and separated. The inspector also observed that the No. 3 cylinder had separated. Further examination of the engine following recovery revealed impact marks on the engine crankcase where the No. 3 cylinder secured to it. The marks were consistent with the cylinder impacting the case multiple times. The examination also revealed that several of the other cylinder nuts were below the required 50 ft/lbs of torque. The six-seat, low-wing, fixed-tricycle-gear airplane was manufactured in 1975. It was powered by a Lycoming IO-540, 300-horsepower engine, equipped with a constant-speed, two-blade Hartzell propeller. Review of maintenance records revealed that the engine's most recent overhaul was completed on November 14, 2006. The airplane's most recent annual inspection was completed on March 16, 2018. At the time, the engine had accrued 353.58 hours since the overhaul. There was no record of any cylinder removal or replacement since the engine overhaul. The airplane had flown about 13 additional hours from the time of the most recent annual inspection, until the accident.

Probable Cause and Findings

A total loss of engine power after the separation of the No. 3 cylinder from the crankcase due to improper maintenance.

 

Source: NTSB Aviation Accident Database

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