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Inadequate maintenance fatal for Piper pilot

By NTSB · March 25, 2019 ·

The airplane owner and a mechanic completed the Piper PA-28-140’s annual inspection the morning of the accident. The mechanic did no work, but returned the airplane to service with an endorsement that the annual inspection/airworthiness requirements had been met based on his determination that the engine runup was satisfactory.

The airplane departed but returned to the airport in Stonewall, Texas, shortly after the departure. During the return, a witness said the plane was “way too high,” and its approach was “pretty steep.”

The airplane touched down about halfway down the short grass runway and was “going way too fast.” The airplane overran the end of the runway and into a pond where it became submerged. The pilot died in the crash.

Post-accident examination of the runway revealed the presence of skid marks from the airplane main landing gear wheels along the last 300′ of the runway. The propeller exhibited rotational signatures but with some loss of torque.

Post-accident examination of the airplane revealed numerous unairworthy maintenance items and/or lack of maintenance to the engine and accessories. Additionally, the engine and various accessories surpassed their manufacturers’ recommended time for overhaul/replacement.

The exhaust manifold was blocked with internal fractured pieces that would have resulted in power loss. The condition of these pieces was consistent with a failure that had been preexisting.

The induction hose to the carburetor was the wrong part for the installation. The hose was collapsed and would have restricted airflow into the carburetor resulting in power loss.

Both magnetos were no longer serviceable and would have produced minimal ignition. The engine timing was not set to the engine manufacturer’s specification.

Had the mechanic conducted a proper annual inspection, he would have identified many of the issues found during the airplane’s post-accident examination.

Based on the evidence, the pilot likely returned to the airport due to a loss of engine power. It could not be determined which of the many discrepancies led to the loss of engine power. Further, the pilot did not attain a power-off approach glideslope that would have led to a proper touchdown point near the approach end of the runway.

Probable cause: The pilot’s failure to attain a proper touchdown point following a loss of engine power and his inability to stop the airplane on the short, soft runway. Contributing to the accident was the inadequate maintenance of the airplane by the owner and the mechanic and the improper annual inspection by the mechanic.

NTSB Identification: CEN17FA139

This March 2017 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.

About NTSB

The National Transportation Safety Board is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation, including railroad, transit, highway, marine, pipeline, and commercial space. It determines the probable causes of accidents and issues safety recommendations aimed at preventing future occurrences.

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Comments

  1. Larry says

    March 26, 2019 at 7:23 am

    “…the engine and various accessories surpassed their manufacturers’ recommended time for overhaul/replacement.” Since when does an engine in an airplane operated privately under Part 91 have a time or age requirement for o/h or replacement? Those recommendations are just that … RECOMMENDATIONS. It’s up to a mechanic to determine if it’s airworthy … or not. I’m not advocating pencil whipping it but the uninitiated might get the wrong idea from that statement.

    Sounds like there were other problems that should have been found by a proper inspection, however, a bigger problem is the pilots flying skills. Even if you accept the premise that the engine wasn’t producing full power, the airplane managed to get itself high enough such that the pilot was trying to get it down and overshot the usable runway. I fail to see how the engine issues are related by the info provided here. Once again, misspelling caused by the pencil.

    This article intimates that the engine somehow caused the pilot to be too high and too fast and failed to find the proper landing zone. The pilot is dead! Unless he was interviewed, that is pure speculation and unfair to manufacturers of the engine and accessories who will likely now be sued. THIS is why aviation is no longer affordable. I hear the wings of liability lawyers circling overhead Stonewall, TX.

  2. Richard Wyeroski says

    March 26, 2019 at 7:13 am

    I perform owner assisted annuals every year. It is a great way for owners to save a little money by doing items under Preventive Maintenance and helping the mechanic. They know their planes well. I try to fly the aircraft with the owner and check the aircraft out in flight. Many engines are older, well past the manufactureres 12 year/2000 hour overhaul cycle.

    I have seen owners replace parts with illegal alternators, wheel bearings, alternator belts to save money. Improper repairs with no log book entries stand out. Store bought rugs, auto parts also stand out!

    Mufflers are a problem and cracked and damaged mufflers can kill. Improper welding, baffle and exhaust pipe cracks are common. THESE PROBLEMS CAN KILL YOU. Worst yet they kill innocent people on the ground!

    Before becoming an A&P/IA I worked with many mechanics and learned from them. As a CFI I know how pilots fly and sometimes without knowing abuse their aircraft.

    We have to remember that we are in the air and can not just pull over…….The FAA unfortunately only reacts after the crash.

    Being in aviation for 50 years, I take a dim view of people that break the regulations and take an attitude that aircraft are like Automobles.

    Every Year we have 1200 accidents, 10,000 incidents and 10’s of thousands of occurrences……Over 500 die every year in accidents.

    We can do better! This fellow that crashed is now a statistic in the NTSB files……

    • smith says

      November 17, 2019 at 6:40 am

      To :Richard Wyeroski
      Are you a former Zahn’s Pilot, if so please contact me.
      I would like to talk about Zahns.
      Regards,
      Smith
      [email protected]

  3. Tom says

    March 26, 2019 at 7:08 am

    One reason I am glad to own an experimental RV. I do the annual ( conditional inspection). If there is something I don’t know or understand I check with my trusted A&P. I’ll ground my plane in a heartbeat if something is wrong or doesn’t sound or feel right and do what’s necessary to correct the problem.

  4. gbigs says

    March 26, 2019 at 6:53 am

    If you don’t know who is working on your plane. And if you don’t have any idea what is supposed to be done on an annual you get what you pay for…

  5. Henry K. Cooper says

    March 26, 2019 at 6:03 am

    There are IAs out there who, for a fee, will conduct a “paper annual”, and owners who will gladly oblige them, as it costs less. Plus, “nothing’s wrong with the airplane”, according to Mr. Owner. As far as I’m concerned, the IA belongs in jail and banned from aviation maintenance, and the pilot/owner needs a similar whack for being a party to it all.

  6. KIRK says

    March 26, 2019 at 5:02 am

    And pilots cant seem to understand why annuals (real annuals) cost money!

  7. Richard Wyeroski says

    March 26, 2019 at 4:49 am

    Stories like this make us all look bad. Why such a complete disregard for the regulations? Fortunately his disregard for safety and trust only resulted in his death and no one else was injured!

  8. T Ibach Jr says

    March 25, 2019 at 8:22 pm

    we had a guy near us a couple of decades back who just told pilots to leave the airplane logs in an old fridge behind his hanger and he would sign the AD notes, annuals, whatever aircraft sight unseen…

    • Robert Hartmaier says

      March 26, 2019 at 4:46 am

      A “hanger” is what you use to hang up shirts in you closet. A “”hangar” is where you store an airplane.

      • Richard Wyeroski says

        March 26, 2019 at 4:51 am

        really!

  9. JimH in CA says

    March 25, 2019 at 7:57 pm

    Another old aircraft with a large number of problems and an ‘annual’ that was ‘pencil whipped’.
    This A&P should be in jail.
    The pilot obviously didn’t care, and doesn’t have any more worries.

    • Klaus says

      March 26, 2019 at 8:53 am

      The rules are written in FAA FAR Part 91 ‘Subpart E—Maintenance, Preventive Maintenance, and Alterations’ (91.4xx). This regulation says it all:

      “91.403 General.

      (a) The owner or operator of an aircraft is primarily responsible for maintaining that aircraft in an airworthy condition, including compliance with part 39 of this chapter.”

      If an owner/operator of any type of vehicle decides to take greater risk, that’s their decision. Not everybody is going to make the same decisions and we don’t have too. That’s what makes this a “Great Country”. “Liberty” comes at a price in so many ways.

      http://www.ecfr.gov/cgi-bin/text-idx?tpl=/ecfrbrowse/Title14/14tab_02.tpl

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