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Mechanic’s lack of experience contributes to crash

By NTSB · January 25, 2021 ·

A maintenance test flight ended in a crash when a Piper PA-32R-300 experienced a total loss of engine power during a visual approach to Runway 5 at Lenawee County Airport (KADG) in Adrian, Michigan.

The airplane hit a fence and terrain short of the runway and sustained substantial damage. The private pilot and an airplane mechanic received minor injuries.

According to the pilot, the flight departed with the airplane mechanic with inspection authorization (IA) who signed off the airplane’s last annual inspection, for a post annual inspection flight. They flew north between Jackson and Lansing, Michigan, and then proceeded southwest to Coldwater, Michigan, and then Hillsdale, Michigan.

They returned for an approach and landing to KADG on Runway 5 with engine power set to 14 inches of manifold pressure, landing gear extended, and flaps extended. On short final for Runway 5, the “engine shut off,” according to the pilot, who added there was “no sputter — it acted as if someone shut off the key.”

Post-accident examination of the engine revealed that the crankshaft gear bolt was fractured through. A logbook entry dated Aug. 24, 2013, at a tachometer time of 3,399.87 hours and a time since overhaul of 0 hours, stated that the engine was disassembled, and an AN8-14 bolt was installed.

Following the accident, FAA inspectors interviewed the airframe and power plant mechanic (AP) who last overhauled the engine. During the interview, he stated he is the owner of a tool and die shop that also does manufacturing of various parts for the auto industry. He spends about 25% of his working time in his hangar performing aircraft repair. He stated that he is most comfortable working on old, small, fabric-covered aircraft.

The AP stated that he was the one that overhauled the engine on N8892E and the IA just removed and re-installed the engine onto the airplane.

The AP also stated that this was the first of the “big” Lycoming engines that he had overhauled. The AP told inspectors that he does not like using the Lycoming manuals, as they are hard to follow. The AP mentioned several times that he had contacted Lycoming to request assistance, and they worked with him in providing the necessary documentation needed for the work he was doing. The AP stated that he did not torque the crankshaft gear bolt to the engine manufacturer’s specifications.

The engine overhaul was signed off by the AP.

A National Transportation Safety Board Materials Laboratory post-accident examination of the bolt revealed that it had fractured 1.038 inches below the bolt head.

The bolt features were consistent with fatigue cracking that initiated at multiple sites near the bottom of a thread root. These smaller cracked coalesced and propagated inward through more than half the crack section of the bolt. The bolt began to cycle under reverse bending, which initiated fatigue cracking at multiple sites along the thread root on the opposite side. Once both cracks had propagated inward to the extent present on the fracture surfaces, the remaining cross section of the bolt fractured from overstress.

Probable Cause: The airframe and powerplant mechanic’s lack of experience in the overhaul of the engine model and the improper torque of the crankshaft gear bolt, which resulted in fatigue failure of the bolt and a total loss of engine power during an approach for landing.

NTSB Identification: 98884

This January 2019 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. John says

    January 27, 2021 at 2:11 pm

    The A&P is a rarity… an honest-to-a-fault guy! Yes, he didn’t know what he was doing, but he didn’t lie about it. When a guy is that forthcoming, I have to wonder about the owner/operator who asked him to overhaul his engine. I agree that shop manuals are not like reading Harry Potter novels. But, the purpose of shop manuals is to describe in excruciating detail how the equipment is put together and how to maintain it.

  2. JimH in CA says

    January 26, 2021 at 2:38 pm

    The question that I have, is why the owner/pilot chose this inexperienced A&P ?
    This A&P has no excuse for not following the manufacturers specifications on proper assembly.
    Torque specs. are easy to find in the manuals.

    The docket does not explain any of this.

    I use an A&P IA that is a retired Air Force mechanic for the 10 years I’ve Owned the Cessna I fly.

  3. SamIAm says

    January 26, 2021 at 10:40 am

    I’m not sure how this report can make me a better pilot…torque everything when returned?

    • Dave says

      January 28, 2021 at 1:25 am

      It’s not all about the pilots, you know. They are also intended to make better mechanics.

    • Greg Wilson says

      January 28, 2021 at 2:43 pm

      This is how it applies to pilots, ” On short final for Runway 5, the “engine shut off,” according to the pilot, who added there was “no sputter — it acted as if someone shut off the key.”
      The engine failure was caused by the mechanic. The crash was caused by improper landing procedures on the part of the pilot. From short final they should have made the runway.

  4. Phil says

    January 26, 2021 at 9:14 am

    Ineptness goes on more than we know.

  5. scott says

    January 26, 2021 at 5:10 am

    Strange that he would say he didn’t torque the bolt to specs as if he did so knowingly.
    This is not a lack of experience, rather a lack of intelligence.

  6. Minor Mech. says

    January 26, 2021 at 2:55 am

    Hand tight and a quarter turn. TLAR.!

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