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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

March 4, 1990 · Piper PA-28-151 · N991DB

Creola, AL

Overview

Report Status
Probable Cause
Event Type
Accident
Date
March 4, 1990
Injury Outcomes
2 injuries (2 serious injuries)
Location
Creola, AL
Aircraft
Piper PA-28-151
Tail Number
N991DB
Injuries
Serious
Aircraft Damage
Substantial
NTSB Number
ATL90FA071

The private pilot was test flying an airplane following a number three cylinder change. On initial climb, the engine began to vibrate, backfire and lose power. The airplane crashed on a highway median located about one mile from the airport center. A post-crash inspection of the engine revealed a piece of exhaust valve lodged in the number one piston head. Another valve fragment was found inside the muffler. The pilot reported that the number three cylinder change was the result of a previously failed number three exhaust valve and subsequent internal damage to the number three cylinder. An assumption was made that the fragments from the failed valve had exited the engine via the exhaust system. A local mechanic changed the cylinder, but did not complete the repair due to a lack of time. The pilot finished the repair, test ran the engine, and flew the airplane on the accident flight. The engine was not certified airworthy prior to the flight.

NTSB Probable Cause

THE PILOT'S FAILURE TO ASSURE THAT PROPER MAINTENANCE AND INSPECTION OF THE AIRCRAFT WERE COMPLETED BEFORE FLIGHT.

Full Narrative

THE PRIVATE PILOT WAS TEST FLYING AN AIRPLANE FOLLOWING A NUMBER THREE CYLINDER CHANGE. ON INITIAL CLIMB, THE ENGINE BEGAN TO VIBRATE, BACKFIRE AND LOSE POWER. THE AIRPLANE CRASHED ON A HIGHWAY MEDIAN LOCATED ABOUT ONE MILE FROM THE AIRPORT CENTER. A POST-CRASH INSPECTION OF THE ENGINE REVEALED A PIECE OF EXHAUST VALVE LODGED IN THE NUMBER ONE PISTON HEAD. ANOTHER VALVE FRAGMENT WAS FOUND INSIDE THE MUFFLER. THE PILOT REPORTED THAT THE NUMBER THREE CYLINDER CHANGE WAS THE RESULT OF A PREVIOUSLY FAILED NUMBER THREE EXHAUST VALVE AND SUBSEQUENT INTERNAL DAMAGE TO THE NUMBER THREE CYLINDER. AN ASSUMPTION WAS MADE THAT THE FRAGMENTS FROM THE FAILED VALVE HAD EXITED THE ENGINE VIA THE EXHAUST SYSTEM. A LOCAL MECHANIC CHANGED THE CYLINDER, BUT DID NOT COMPLETE THE REPAIR DUE TO A LACK OF TIME. THE PILOT FINISHED THE REPAIR, TEST RAN THE ENGINE, AND FLEW THE AIRPLANE ON THE ACCIDENT FLIGHT. THE ENGINE WAS NOT CERTIFIED AIRWORTHY PRIOR TO THE FLIGHT.

Flight

Event TypeAccident
Event Time11:19 CST
Nearest Airport0nm N
Runway0
Runway Length0
Runway Width0
Flight Plan FiledNone
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftPiper PA-28-151
Tail NumberN991DB
Aircraft CategoryAir
DamageSubstantial
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsLycoming · O-320-E3D · Reciprocating · 150
Seats4

People & Injuries

Injury Summary2 injuries (2 serious injuries)
Fatal0
Serious2
Minor0
Uninjured0
Total2
Crew 1Age 39 · Third Class

Conditions

ConditionsVMC
LightDaylight
Wind360° @ 7 kt
Visibility15 sm
CeilingNone
Temperature / Dew Point64 F / 0 C
Altimeter30.00 inHg
Observation Time17:08
Weather SourceWFAC

Appendix: Source Data