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Failure to remove engine cowl plugs results in crash

By NTSB · September 18, 2019 ·

The FAA aviation safety inspector reported that, during a telephone conversation, the pilot reported that, during the climb, he noticed the engine cylinder heat temperature gauge exceeded 500°F.

He immediately turned back to the departure airport in Orange, Massachusetts. While in the downwind for the landing runway, the engine lost power.

The Van’s RV-8 immediately lost altitude and cleared a tree line in the path to the runway, but then hit terrain hard in a base-to-final flightpath near the runway threshold.

When he got out of the airplane, he observed an engine cowl plug installed on the right side of the engine cowl and removed it.

The right wing and fuselage sustained substantial damage.

The FAA inspector reported that he traveled to the accident, and while on-site, he observed the left cowl plug melted onto the engine cylinders. He added that the right cowl plug was found on the ground near the airplane.

Probable cause: The pilot’s failure to remove the engine cowl plugs during preflight, which resulted in excessive engine cylinder head temperatures during climb and a total loss of engine power.

NTSB Identification: GAA17CA557

This September 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. Cat Herder & Pilot says

    September 21, 2019 at 1:36 pm

    Reading all those arm chair comments, I am pleased to be surrounded by so many social media aces. Remember the NTSB report says…”provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.” Maybe we shouldn’t be so self righteous?

    • Dale L. Weir says

      September 23, 2019 at 1:06 pm

      You are correct in pointing out the educational tool part, but there are “Air Gods” out there that truly believe they will ever make a mistake and use the comment section to remind everyone else that they are mere mortals.
      Me…..just a high time Student Pilot. Always something to learn from other pilots misfortunes as well as my own mistakes.

  2. JOHN SWALLOW says

    September 21, 2019 at 8:55 am

    You really don’t want to know how I managed to fire up a helicopter with the rotor free to turn but the tie down still attached to the blade… (;>0)

    • Dale L. Weir says

      September 23, 2019 at 12:52 pm

      Weaverville, California….CDF UH-1?

      • JOHN SWALLOW says

        September 23, 2019 at 2:09 pm

        Dale:

        Corporate aviation in a JetRanger. Interrupted while walking blade backwards to tie down. When returned an hour later, blade was at ninety degree position (proper for start up), pilot walked by dangling nylon strap, and fired up.

        Managed to shut down before any damage – through good luck, not good management.

        • Dale L. Weir says

          September 24, 2019 at 11:10 am

          It is a nice change of pace for someone to own up to making a mistake, rather than just posting arrogant remarks that do nothing for “ learning from the misfortunes of others”. Certainly made enough of my own to fill an entire book.

  3. JimH in CA says

    September 20, 2019 at 3:13 pm

    When I was renting aircraft, the cowl plugs were attached with a cord, which was wrapped around the prop.
    If you didn’t notice the 2 orange flags, when the engine started, the plugs were thrown off in a wild arc.!
    Then the pilot would pay for new cowl plugs or have a new cord attached.
    But the aircraft never even taxied with the plugs in.!

  4. Phil says

    September 19, 2019 at 10:50 am

    How about cowl plugs with flags that stick up over the cowl so you can see them from the cockpit?

    • Richard says

      September 21, 2019 at 6:20 am

      That is a great idea. You should patent it and make them available.

    • Henry K. Cooper says

      November 29, 2019 at 6:06 am

      Bow about doing a decent preflight in the first place?

  5. walter m krupnak says

    September 19, 2019 at 10:16 am

    With that kind of CHT’s why did he even fly a normal traffic pattern. He should of (announced on CTAF) his problem and got on the runway ASAP. Some people should not even be flying aircraft!!!

  6. Terk Williams says

    September 19, 2019 at 7:40 am

    We had a great deal of Spring bird activity and were putting the cowl plugs in after EVERY flight. I had a very seasoned instructor and competent pilot working on a tailwheel transition. They each ASSUMED… the other had gotten the plugs. About 3,000’ over a lovely sod farm they first cooked one of the mags and as they refused to accept the insidious but obvious evolving failure they never turned to the airport, less than 3 mi away. Eventually the other mag cooked and the ultimate forced landing, from 400’, was to the plowed dirt quadrant of the otherwise grassy sod farm. Refusing to accept the failure and thinking their combined exceptional piloting skills would somehow make the problem go away resulted in having to trailer it home…. Sounds easy… but… insidious… well… one very small bite/100’ at a time is often worse than a massive failure. OH… we were talking about cowl plugs… that old chain of events thing…

  7. J Hann says

    September 18, 2019 at 11:58 am

    We all makes mistakes one way or another but it seems a preflight was not in the cards on this one.

    • gbigs says

      September 19, 2019 at 6:06 am

      There should never be “a preflight was not in the cards” but if someone is prone to skipping or rushing through their preflight they deserve what they get.

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