Sunday, May 12, 2019

Powerplant System / Component Malfunction / Failure: Piper PA-28-140, N2804T; accident occurred August 15, 2017 near Cherokee County Airport (KCNI), Canton, Georgia


The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Atlanta, Georgia
Power Flow Systems Inc; Daytona Beach, Florida 

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

http://registry.faa.gov/N2804T



Location: Canton, GA
Accident Number: ERA17LA277
Date & Time: 08/15/2017, 1635 EDT
Registration: N2804T
Aircraft: PIPER PA28
Aircraft Damage: Substantial
Defining Event: Powerplant sys/comp malf/fail
Injuries: 2 Minor
Flight Conducted Under: Part 91: General Aviation - Instructional 

Analysis 

According to the flight instructor, during the takeoff roll, he noted that the airplane felt "sluggish." After checking all systems, he and the student pilot continued the takeoff. The flight instructor noted that, after climbing to 200 ft, the airspeed began to decrease while the engine continued to produce power. The flight instructor performed an emergency landing in a wooded area, which resulted in substantial damage to the wings and fuselage. An examination of the airplane revealed that the carburetor throttle linkage was striking against the exhaust shield, which prevented the carburetor throttle linkage from its full movement at full throttle. A review of the maintenance logbooks revealed that a new exhaust system was recently installed on the engine. It is likely that maintenance personnel failed to ensure that the throttle linkage was properly adjusted, which prevented the throttle from opening fully and resulted in the engine being unable to produce full static power.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
Maintenance personnel's failure to ensure the proper throttle linkage travel clearance after the installation of an exhaust system.

Findings

Aircraft
Power lever - Not inspected (Cause)

Personnel issues
Installation - Maintenance personnel (Cause)

Factual Information

On August 15, 2017, about 1635 eastern daylight time, a Piper PA-28-140, N2804T, was substantially damaged during a forced landing after takeoff from the Cherokee County Airport (CNI), Canton, Georgia. The flight instructor and student pilot sustained minor injuries. The instructional flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the local flight.

According to the flight instructor, after an uneventful engine run-up, they taxied to the active runway for takeoff. As the takeoff roll commenced, he noted that the airplane felt "sluggish." He asked the student pilot if he had his foot on the brakes, and the student pilot replied "no." The flight instructor checked the throttle and airspeed and noted that the throttle was full forward and the airspeed was increasing slowly. Once the airplane reached 75 knots, the airplane lifted off the runway and began to climb. The climb appeared normal for approximately the first 200 ft. Then, the flight instructor noticed that the airspeed was decreasing but the engine never stopped. He took over the flight controls and elected to perform an emergency landing in a wooded area.

Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that both wings separated from the fuselage and the fuselage of the airplane was buckled. A post-crash fire ensued within the engine cowling and spread to the cockpit. An examination of the engine revealed that the carburetor throttle linkage was striking against the exhaust heat shield. This prevented the carburetor throttle linkage from its full movement at full throttle. A review of the maintenance logbooks revealed that on July 28, 2017, a Power Flow exhaust system was installed on the engine. The airplane accumulated about 6 hours of flight time prior to the accident event. 

History of Flight

Prior to flight
Aircraft maintenance event

Initial climb
Powerplant sys/comp malf/fail (Defining event)

Emergency descent
Off-field or emergency landing
Collision with terr/obj (non-CFIT)




Pilot Information

Certificate: Flight Instructor; Commercial
Age: 63, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Single-engine
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 12/22/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 12/08/2016
Flight Time:  3623 hours (Total, all aircraft), 987 hours (Total, this make and model), 3518 hours (Pilot In Command, all aircraft), 16 hours (Last 90 days, all aircraft), 10 hours (Last 30 days, all aircraft)

Student Pilot Information

Certificate: Student
Age: 50, Male
Airplane Rating(s): None
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification:  None 
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  (Estimated) 12 hours (Total, all aircraft), 12 hours (Total, this make and model)



Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N2804T
Model/Series: PA28 140
Aircraft Category: Airplane
Year of Manufacture: 1972
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 28-7225235
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 04/12/2017, Annual
Certified Max Gross Wt.: 2300 lbs
Time Since Last Inspection: 76 Hours
Engines: 1 Reciprocating
Airframe Total Time: 7976.09 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: Installed, not activated
Engine Model/Series: O-320-E3D
Registered Owner: On file
Rated Power: 150 hp
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: CNI, 1219 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1635 EDT
Direction from Accident Site: 0°
Lowest Cloud Condition: Scattered / 2800 ft agl
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR): 
Wind Speed/Gusts: 4 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 280°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.98 inches Hg
Temperature/Dew Point: 30°C / 24°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: CANTON, GA (CNI)
Type of Flight Plan Filed: None
Destination: Canton, GA (CNI)
Type of Clearance: None
Departure Time: 1635 EDT
Type of Airspace: Class G

Airport Information

Airport: CHEROKEE COUNTY (CNI)
Runway Surface Type: Asphalt
Airport Elevation: 1219 ft
Runway Surface Condition: Dry
Runway Used: 5
IFR Approach: None
Runway Length/Width: 5001 ft / 75 ft
VFR Approach/Landing: Forced Landing

Wreckage and Impact Information

Crew Injuries: 2 Minor
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion:None 
Total Injuries: 2 Minor
Latitude, Longitude:  34.312222, -84.422222 (est)

3 comments:

Cruzinchris said...

I can't believe a CFI would think the airplane is sluggish on takeoff and not abort. What was he thinking? Just like the go-around syndrom, pilots are thinking of a reason to not do it. If you think you should abort or go-around, for gosh sakes, DO IT!

Anonymous said...

I'm missing something. If the throttle was blocked, why would it climb 200 feet and then lose more power? Maybe you had to be there, but I would question the decision to put a flyable airplane into trees. Yes it's better than a stall/spin, but they were damn lucky to walk away from this.

Anonymous said...

My take away was that they delayed rotation, had built up some speed, and then after rotation the partial power was insufficient to continue flying, they bled off what little excess energy they had built up on the ground and settled back toward the ground.