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Aviation safety reports, made easier to study

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NTSB Report

April 9, 1992 · Piper PA-32R-301T PA-32R-301 · N8194X

Albuquerque, NM

Overview

Report Status
Probable Cause
Event Type
Accident
Date
April 9, 1992
Injury Outcomes
1 injury (1 fatality)
Location
Albuquerque, NM
Aircraft
Piper PA-32R-301T PA-32R-301
Tail Number
N8194X
Operator
New Mexico Transportation Dept
Injuries
Fatal
Aircraft Damage
Substantial
NTSB Number
FTW92GA111

The airplane sustained an in-flight fire and during the forced landing impacted the terrain nose low. According to ATC, the pilot diverted to an alternate airport after reporting smoke in the cockpit. According to witnesses, the pilot did not shut down the engine. Witnesses reported that the airplane entered a downwind pattern and impacted the terrain after overshooting the runway during the approach. Investigation revealed that the fuel line to the No. 5 cylinder had separated over time by cyclic stresses that propagated a fatigue crack. The maintenance installation of the line had been improperly routed and the line not clamped. Manufacturer information on the line routing and clamps had not been available in the service bulletins. The exhaust pipe exhibited mechanical abrasion and thermal oxidation prior to the accident although the exhaust system had undergone a recent maintenance check. A 'B' nut missing on the top spark plug for the No. 5 cylinder had been situated at a location of intense heat during the in-flight fire. Surface cracks penetrating the inside surface of the V-band coupling securing the exhaust pipe exhibited surface oxidation damage determined to be in existence for some time prior to the accident.

NTSB Probable Cause

FUEL LINE FAILURE DUE TO VIBRATORY FATIGUE. FACTORS WERE IMPROPER MAINTENANCE, MANUFACTURER INFORMATION FOR FUEL LINE NOT AVAILABLE, AND THE PILOTS' FAILURE TO FOLLOW EMERGENCY PROCEDURES.

Full Narrative

THE AIRPLANE SUSTAINED AN IN-FLIGHT FIRE AND DURING THE FORCED LANDING IMPACTED THE TERRAIN NOSE LOW. ACCORDING TO ATC, THE PILOT DIVERTED TO AN ALTERNATE AIRPORT AFTER REPORTING SMOKE IN THE COCKPIT. ACCORDING TO WITNESSES, THE PILOT DID NOT SHUT DOWN THE ENGINE. WITNESSES REPORTED THAT THE AIRPLANE ENTERED A DOWNWIND PATTERN AND IMPACTED THE TERRAIN AFTER OVERSHOOTING THE RUNWAY DURING THE APPROACH. INVESTIGATION REVEALED THAT THE FUEL LINE TO THE NO. 5 CYLINDER HAD SEPARATED OVER TIME BY CYCLIC STRESSES THAT PROPAGATED A FATIGUE CRACK. THE MAINTENANCE INSTALLATION OF THE LINE HAD BEEN IMPROPERLY ROUTED AND THE LINE NOT CLAMPED. MANUFACTURER INFORMATION ON THE LINE ROUTING AND CLAMPS HAD NOT BEEN AVAILABLE IN THE SERVICE BULLETINS. THE EXHAUST PIPE EXHIBITED MECHANICAL ABRASION AND THERMAL OXIDATION PRIOR TO THE ACCIDENT ALTHOUGH THE EXHAUST SYSTEM HAD UNDERGONE A RECENT MAINTENANCE CHECK. A 'B' NUT MISSING ON THE TOP SPARK PLUG FOR THE NO. 5 CYLINDER HAD BEEN SITUATED AT A LOCATION OF INTENSE HEAT DURING THE IN-FLIGHT FIRE. SURFACE CRACKS PENETRATING THE INSIDE SURFACE OF THE V-BAND COUPLING SECURING THE EXHAUST PIPE EXHIBITED SURFACE OXIDATION DAMAGE DETERMINED TO BE IN EXISTENCE FOR SOME TIME PRIOR TO THE ACCIDENT.

Flight

Event TypeAccident
Event Time17:20 MDT
Nearest AirportCORONADO (1nm NE)
Runway3
Runway Length3500 ft
Runway Width40 ft
Flight Plan FiledNone
Aircraft FireIflt
Aircraft ExplosionNo

Aircraft

AircraftPiper PA-32R-301T PA-32R-301
Tail NumberN8194X
Aircraft CategoryAir
DamageSubstantial
OperatorNew Mexico Transportation Dept
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsLycoming · TIO-540-S1AD · Reciprocating · 300
Seats6

People & Injuries

Injury Summary1 injury (1 fatality)
Fatal1
Serious0
Minor0
Uninjured0
Total1
Crew 1Age 62 · Second Class

Conditions

ConditionsVMC
LightDaylight
Wind320° @ 5 kt
Visibility60 sm
CeilingNone
Temperature / Dew Point18 C
Altimeter29.00 inHg
Observation Time22:50
Weather SourceWFAC

Appendix: Source Data