Saturday, March 14, 2020

Loss of Engine Power (Partial): Piper PA-28-140 Cherokee, N8447R; accident occurred March 12, 2017 near Peter O. Knight Airport (KTPF), Tampa, Hillsborough County, Florida

Main Wreckage

Induction duct

View down collapsed duct


Side view of collapsed duct-removed

Accident Duct and Exemplar (Approved) Duct 

Accident Duct and Exemplar (Approved) Duct 







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

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Tampa, 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/N8447R


Location: Tampa, FL
Accident Number: ERA17LA128
Date & Time: 03/12/2017, 1335 EDT
Registration: N8447R
Aircraft: PIPER PA28
Aircraft Damage: Substantial
Defining Event: Loss of engine power (partial)
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis 

The private pilot stated that he rented the airplane 2 days before the accident flight to fly across the state for several days. On the day of the accident, the pilot performed a preflight inspection of the airplane with no anomalies noted. After takeoff and during the initial climb, the pilot noticed a loss of engine power, and the rpm started to drop. He attempted to return to the departure airport and land on an intersecting runway, but during the turn, he realized he would not make it back to the airport; he ditched the airplane into the surrounding water. The airplane was substantially damaged during the ditching.

Postaccident examination of the airplane revealed that the induction duct from the air filter to the carburetor had collapsed, which likely restricted air flow to the engine and ultimately resulted in the loss of engine power. Further examination revealed that the induction duct on the accident airplane was not approved for installation on the engine. About 3 years before the accident, the Federal Aviation Administration had issued a special airworthiness information bulletin recommending operators inspect airplanes of this model to ensure that the correct induction duct was installed; that there was no loose or displaced supporting wire or signs of wear, perforation, or deterioration; and that the part had not collapsed. However, the operator was unaware of the bulletin and had not performed the inspection. After the accident, the operator inspected the fleet and installed the approved part on all affected airplanes. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
A collapsed engine induction duct, which resulted in restricted air flow to the engine and a subsequent loss of engine power. Contributing to the accident was the operator's failure to ensure that the correct induction duct was installed.

Findings

Aircraft
Scheduled maint checks - Incorrect service/maintenance (Cause)
Air intake - Failure (Cause)

Environmental issues
Water - Contributed to outcome


Factual Information

On March 12, 2017, about 1335 eastern daylight time, a Piper PA-28-140, N8447R, impacted the water during a forced landing shortly after takeoff from Peter O Knight Airport (TPF), Tampa, Florida. The private pilot was not injured. Visual meteorological conditions prevailed and no flight plan was filed for the flight to Sebastian Municipal Airport (X26), Sebastian, Florida. The personal flight was conducted in accordance with the provisions of 14 Code of Federal Regulations Part 91.

According to the pilot, he rented the airplane two days prior to the accident flight, to fly from X26 to TPF for several days. The flight on March 10 was uneventful. On March 12, he arrived at the airport around 1230 and started his preflight inspection of the airplane. The pilot stated he "sumped" the tanks and the fuel was clear of debris. The rest of the preflight inspection was normal and no anomalies were noted. The engine run-up and magneto checks were normal, and he started his take-off roll on runway 22.

At 60 knots airspeed, he rotated and started to climb. Upon reaching about 100 ft above ground level, he noticed a loss of engine power and the rpm started to drop. He verified fuel and oil pressure were good and started looking for a place to land. He further stated he could not abort the take-off and land safely on the runway, so he decided to try to turn back to the airport and land on the cross runway. During the turn, he realized he would not make it back to the airport and decided to ditch the airplane into the surrounding water. Once he ditched the airplane, he exited through the cockpit door and a local boater picked him up and took him to shore.

Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the left wing separated from the airplane. The windshield was fractured in several areas and the right wing leading edge was damaged.

Further examination of the wreckage by an investigator with the National Transportation Safety Board revealed the induction hose from the air filter to the carburetor was collapsed and the spring inside the duct was positioned sideways.

The duct was sent to the airframe manufacturer for a visual examination. The examination revealed that the duct was not approved for installation on the PA-28-140 aircraft. Specifically, duct was not of a type that was approved for negative pressure environments. Also, the duct was not of the correct length, and it was not a double walled duct. Based on available information, it could not be determined when the duct had been installed onto the airplane.

The FAA issued a Special Airworthiness Information Bulletin (SAIB), CE-14-23, on August 6, 2014, which recommended that operators and owners of the PA-28 inspect the air inlet hose [duct] and verify that it was an approved part and did not exhibit any loose or broken cords on the external surface. The inspection should also confirm that there was no loose or displaced supporting wire, or signs of wear, perforation, deterioration, and that the part had not collapsed. If any of these conditions were observed, then the hose must be replaced before next flight.

The operator reported that they were unaware of the SAIB, and following the accident, immediately grounded their fleet of airplanes and inspected them for the approved Piper duct. They found that all the airplanes had the unapproved duct installed and immediately ordered and installed the approved part.

Pilot Information

Certificate: Private
Age: 44, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 05/14/2012
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  231 hours (Total, all aircraft), 75 hours (Total, this make and model), 135 hours (Pilot In Command, all aircraft), 10 hours (Last 90 days, all aircraft), 6 hours (Last 30 days, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N8447R
Model/Series: PA28 140
Aircraft Category: Airplane
Year of Manufacture: 1966
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 28-22331
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 01/07/2017, Annual
Certified Max Gross Wt.: 2150 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 5400 Hours at time of accident
Engine Manufacturer: LYCOMING
ELT: C91 installed, not activated
Engine Model/Series: 0-320 SERIES
Registered Owner: On file
Rated Power: 140 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: KTPF, 8 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 0735 UTC
Direction from Accident Site: 7°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 100°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.06 inches Hg
Temperature/Dew Point: 21°C / 17°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Tampa, FL (TPF)
Type of Flight Plan Filed: None
Destination: SEBASTIAN, FL (X26)
Type of Clearance: VFR
Departure Time: 1537 EDT
Type of Airspace: Class E 

Airport Information

Airport: PETER O KNIGHT (TPF)
Runway Surface Type: Concrete
Airport Elevation: 7 ft
Runway Surface Condition: Dry
Runway Used: 22
IFR Approach: None
Runway Length/Width: 3583 ft / 100 ft
VFR Approach/Landing: Forced Landing

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude: 27.910556, -82.449722 (est)

2 comments:

  1. Shame to crash because of unauthorized part number substitution. Must have been a lot of Pipers out in the field where the original hose got old and someone swapped in the similar looking but non-negative pressure service "scat" hose.

    https://rgl.faa.gov/Regulatory_and_Guidance_Library/rgSAIB.nsf/dc7bd4f27e5f107486257221005f069d/5902938699ec35fc86257d2c005492f6/$FILE/CE-14-23.pdf

    ReplyDelete
  2. With the wings off there's a lot more parking.

    ReplyDelete