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Aviation safety reports, made easier to study

NTSB Reports is an independent research and search tool for public aviation accident and incident records. It brings NTSB aviation reports, structured fields, docket files, extracted figures, photos, videos, and update history into one searchable interface.

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NTSB Report

May 20, 1996 · Piper PA-32 · N9164B

Jacksonville, FL

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
May 20, 1996
Injury Outcomes
3 injuries (1 serious injury, 2 minor injuries)
Location
Jacksonville, FL
Aircraft
Piper PA-32
Tail Number
N9164B
Operator
Roger C Doerr
Injuries
Serious
Aircraft Damage
Substantial
NTSB Number
MIA96LA142

The pilot made an emergency landing to an airport after informing ATC that the engine had sustained a partial loss of engine power. Witnesses observed the airplane touch down extremely fast, long, and initiate a go-around. The airplane was observed in a nose high, climbing right turn, and a lack of airspeed. The nose dropped down, and the airplane collided with the trees and terrain in a nose down attitude. Disassembly of the engine revealed the piston plugs on the Nos.3 and 5 cylinders were installed on the forward sides of both pistons. This allowed the unprotected ends of the pins to rub against the cylinder walls. The remaining cylinder assemblies were correctly installed. Review of the engine logbook revealed the engine had not been disassembled since assembly by the manufacturer.

NTSB Probable Cause

The pilot's failure to maintain airspeed (VSO) while maneuvering during a go-around, resulting in an inadvertent stall and subsequent in-flight collision with terrain. Contributing to the accident was the pilot's failure to achieve the proper touchdown point during an emergency landing, his decision to make a go-around with a known mechanical deficiency (partial loss of engine power) due to the improper installation of the piston plugs during assembly of the engine by the manufacturer.

Full Narrative

On May 20, 1996, about 1435 eastern daylight time, a Piper PA-32, N9164B, registered to SAF T Flyers Inc., operating as a 14 CFR Part 91 personal flight, crashed during a forced landing in the vicinity of Jacksonville, Florida. Visual meteorological conditions prevailed and an IFR flight plan was filed. The airplane sustained substantial damage. The commercial pilot sustained serious injuries, and the two passengers sustained minor injuries. The flight originated from Craig Municipal Airport, Jacksonville, Florida, about 5 minutes before the accident. The pilot stated to the FAA, he departed Craig, IFR en route to Vero Beach, Florida. Shortly after being handed off to departure control, he advised the controller that two engine cylinders had stopped producing power. The controller provided radar vectors back to Craig, and he made a visual no flap approach to runway 32. The approach was "extremely hot." He attempted to reduce engine power with negative results. The airplane touched down half way down the runway at about 80 knots, and started sliding and fishtailing from left to right. He initiated a go-around, became airborne, and made a climbing right turn in an attempt to return to the airport; however the engine was not producing sufficient power to sustain flight, and he elected to make a forced landing to a highway. The airplane appeared to descend rapidly as if in a stall, and impacted with trees and the ground. The General Aviation Manager for the Jacksonville Port Authority, located at Craig Airport, stated he was at the fire station when the control tower informed them about N9164B. He left the fire station in a fire truck and went to the vicinity of runway 32. N9164B was observed on about a 1 mile final. The airplane crossed the end of the runway very fast , touched down about 1,000 feet down the runway on the nose wheel, and "wheel barrowed" for some distance. "The aircraft reached the end of runway 32, and lifted back into the air and climbed straight ahead to approximately 100 to 200 feet and started a right turn. I knew the airplane would not make it because of the nose high attitude and lack of airspeed. The airplane started to descend and the right turn increased, and the nose dropped to about 30 to 40 degrees nose low and went into the trees." Review of the engine logbook revealed the engine has not been disassembled since it was manufactured. The engine has accumulated 920 total hours. Examination of the crash site by the FAA revealed the airplane collided with trees in a nose low attitude and came to rest on a heading of 190 degrees magnetic. The propeller and engine assembly separated and was displaced to the right of the main wreckage. Torsional twisting, "s" bending and chordwise scarring was present on all propeller blades. All propeller blades were bent aft and two propeller blade tips were curled forward. The left wing separated at the wing root and the right wing remained attached to the cabin structure. The left fuel tank was ruptured, and the right fuel tank was not ruptured. Examination of the airframe, flight control system, and flight control quadrant revealed no evidence of a precrash mechanical failure or malfunction. All components necessary for flight were present at the crash site. Continuity of the flight control system was confirmed for pitch, roll, and yaw. Examination of the engine assembly by the FAA revealed the rocker arms on the No. 1 and No. 2 cylinders would not operate when the crank shaft was rotated by hand. All engine cylinders were removed to examine cam shaft condition and operation. The piston in the No. 5 cylinder had a large section of the piston skirt and internal areas of the piston pin boss missing. The piston pin plugs were installed on the forward side of the piston allowing the unprotected ends of the pins to rub against the cylinder. Examination of the No. 3 piston revealed the piston pin plugs were installed in the same configuration, however, the piston bosses had not failed. The remaining cylinder assemblies were correctly installed. Examination of the No.3 and No. 5 cylinder assemblies was performed by the NTSB materials laboratory. The examination revealed that the two piston plugs were installed on the forward sides of both pistons allowing the unprotected ends of the pins to rub against the cylinder walls. The No. 5 cylinder outer portion of the pin boss was broken off on the aft side of the cylinder. Binocular microscopic examination revealed that the fracture was not covered with combustion deposits and contained no evidence of preexisting cracking. Further examination disclosed that the inner portions of both the aft and forward pin bosses were also broken off indicative of fatigue cracking. (For additional information, see NTSB Metallurgist's Factual Report No. 96-163.) The No. 3 and No. 5 cylinder and piston assemblies were released to Faith A. Collins, Sample International, on October 7, 1996.

Flight

Event TypeAccident
Event Time14:35 EDT
Nearest AirportCraig Municipal (0nm)
Runway32
Runway Length4007 ft
Runway Width100 ft
Flight Plan FiledIFR
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftPiper PA-32
Tail NumberN9164B
Aircraft CategoryAir
DamageSubstantial
OperatorRoger C Doerr
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsLycoming · IO-540-K1G5 · Reciprocating · 300
Seats6

People & Injuries

Injury Summary3 injuries (1 serious injury, 2 minor injuries)
Fatal0
Serious1
Minor2
Uninjured0
Total3
Crew 1Age 58 · Third Class

Conditions

ConditionsVMC
LightDaylight
Wind130° @ 9 kt
Visibility7 sm
CeilingNone
Temperature / Dew Point70 F
Altimeter29.00 inHg
Observation Time18:40
Weather SourceWFAC

Appendix: Source Data