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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 1, 1991 · Piper PA-31B-310 · N7407L

Bennett, CO

Overview

Report Status
Probable Cause
Event Type
Accident
Date
May 1, 1991
Injury Outcomes
1 injury (1 fatality)
Location
Bennett, CO
Aircraft
Piper PA-31B-310
Tail Number
N7407L
Operator
John Westbrook
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
DEN91FA065

Shortly after takeoff, while climbing to cruise altitude, the pilot reported the left engine cowl assembly had come off. Witnesses observed the airplane at low altitude and noted that it was "yawing, sputtering, and rocking back and forth." They indicated the left engine was not running and that the airplane banked sharply to the right and disappeared behind trees before crashing. An investigation revealed the left propeller had not been feathered. The left engine cowling was found 1.8 miles from the accident site. The three primary (eyebolt) cowl fasteners on the outboard side of the left upper cowl were found unlocked and seven other cowl attaching studs (screws) were missing. The cowling had been removed 16 days before the accident to install an oil/air separator. This was the first flight since that work was performed. The mechanic, who did the work, said he noted several cowl stud fasteners were missing and that he had notified the pilot. The pilot was reported to have replied that he had some fasteners and would take care of the problem.

NTSB Probable Cause

IN-FLIGHT SEPARATION OF THE LEFT ENGINE COWL ASSEMBLY THAT WAS NOT PROPERLY LATCHED, AND FAILURE OF THE PILOT TO MAINTAIN MINIMUM CONTROL SPEED, WHICH RESULTED IN HIS LOSS OF AIRCRAFT CONTROL. FACTORS RELATED TO THE ACCIDENT WERE: AN INADEQUATE PREFLIGHT INSPECTION, INADEQUATE MARKINGS/ALIGNMENT INDICATIONS TO ASSURE THAT THE COWL FASTENERS WERE LOCKED, AND AN INSUFFICIENTLY DEFINED PROCEDURE IN THE FLIGHT MANUAL FOR CHECKING THE COWL FASTENERS.

Full Narrative

SHORTLY AFTER TAKEOFF, WHILE CLIMBING TO CRUISE ALTITUDE, THE PILOT REPORTED THE LEFT ENGINE COWL ASSEMBLY HAD COME OFF. WITNESSES OBSERVED THE AIRPLANE AT LOW ALTITUDE & NOTED THAT IT WAS 'YAWING, SPUTTERING, AND ROCKING BACK AND FORTH.' THEY INDICATED THE LEFT ENGINE WAS NOT RUNNING & THAT THE AIRPLANE BANKED SHARPLY TO THE RIGHT & DISAPPEARED BEHIND TREES BEFORE CRASHING. AN INVESTIGATION REVEALED THE LEFT PROPELLER HAD NOT BEEN FEATHERED. THE LEFT ENGINE COWLING WAS FOUND 1.8 MILES FROM THE ACCIDENT SITE. THE THREE PRIMARY (EYEBOLT) COWL FASTERERS ON THE OUTBOARD SIDE OF THE LEFT UPPER COWL WERE FOUND UNLOCKED & SEVEN OTHER COWL ATTACHING STUDS (SCREWS) WERE MISSING. THE COWLING HAD BEEN REMOVED 16 DAYS BEFORE THE ACCIDENT TO INSTALL AN OIL/AIR SEPARATOR. THIS WAS THE FIRST FLIGHT SINCE THAT WORK WAS PERFORMED. THE MECHANIC, WHO DID THE WORK, SAID HE NOTED SEVERAL COWL STUD FASTENERS WERE MISSING & THAT HE HAD NOTIFIED THE PILOT. THE PILOT WAS REPORTED TO HAVE REPLIED THAT HE HAD SOME FASTENERS & WOULD TAKE CARE OF THE PROBLEM.

Flight

Event TypeAccident
Event Time06:53 MDT
Nearest Airport0nm N
Runway0
Runway Length0
Runway Width0
Flight Plan FiledNone
Aircraft FireGrd
Aircraft ExplosionGrd

Aircraft

AircraftPiper PA-31B-310
Tail NumberN7407L
Aircraft CategoryAir
DamageDestroyed
OperatorJohn Westbrook
Operating RulePart 91
Engines2
Engine TypeReciprocating
Engine DetailsLycoming · TIO-540-A2B · Reciprocating · 310
Seats6

People & Injuries

Injury Summary1 injury (1 fatality)
Fatal1
Serious0
Minor0
Uninjured0
Total1
Crew 1Age 45 · Third Class

Conditions

ConditionsVMC
LightDaylight
Wind150° @ 3 kt
Visibility50 sm
CeilingNone
Temperature / Dew Point0 C / 0 C
Altimeter0
Observation Time12:57
Weather SourceWFAC

Appendix: Source Data