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NTSB Report

September 23, 2024 · Piper PA28 161 · N4298V

Lagrange, GA

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
September 23, 2024
Injury Outcomes
2 injuries (2 minor injuries)
Location
Lagrange, GA
Aircraft
Piper PA28 161 (1983)
Tail Number
N4298V
Operator
Airventures
Injuries
Minor
Aircraft Damage
Substantial
NTSB Number
ERA24LA392

The flight instructor and student pilot had completed maneuvers over the local area before the student pilot performed a touch-and-go landing. During initial climb after the touch-and-go landing, about 200 to 300 ft above ground level, the engine began to run rough and the airplane stopped climbing. The flight instructor then took control of the airplane from the student pilot and made a right turn for a forced landing on a perpendicular runway. The flight instructor stated that during the landing attempt, the engine power did not reduce to idle when the instructor pulled the throttle lever fully aft. The airplane subsequently touched down long on the 5,000-ft runway and traveled off the end and down an embankment, coming to rest upright. Postaccident examination of the engine did not reveal any anomalies with the throttle linkage. However, the No. 3 cylinder exhaust valve was stuck in the open position. Metallurgical examination of the No. 3 cylinder revealed rough residues and patches in the valve guide, as well as valve guide material that had adhered to the exhaust valve stem. Caked residues were observed around the exhaust valve tip. Measurements of the exhaust valve guide bore’s inside diameter were all below specification for a new valve guide, and the diametral valve-to-guide clearances were also below specification at the middle and inboard end of the guide. The cylinder had been operated for about 1,072 hours since it was installed new about 3 years before the accident. Available evidence indicates that, over time, the improperly manufactured exhaust valve guide bore allowed a build-up of residual material that led to the exhaust valve becoming stuck in the open position and a partial loss of engine power.

NTSB Probable Cause

Improper manufacture of a cylinder exhaust valve guide by the engine manufacturer, which resulted in a stuck exhaust valve and a partial loss of engine power during initial climb.

Full Narrative

On September 23, 2024, about 1442 eastern daylight time, a Piper PA-28-161, N4298V, was substantially damaged when it was involved in an accident near LaGrange, Georgia. The flight instructor and student pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that after completing maneuvers over the local area, the student pilot performed a touch-and-go landing on runway 31 at LaGrange-Calloway Airport (LGC), LaGrange, Georgia. During the initial climb after the touch-and-go landing, about 200 to 300 ft above ground level, the engine began to run rough and the airplane stopped climbing. The flight instructor then took control of the airplane from the student pilot and made a right turn for a forced landing on runway 21. The flight instructor further stated that during the landing attempt, the engine power did not reduce all the way to idle when he pulled the throttle lever fully aft. The airplane subsequently touched down long on the 5,000-ft runway and traveled off the end and down an embankment, coming to rest upright. Examination of the wreckage revealed that the landing gear collapsed and the left wing was substantially damaged. The wreckage was retained for further examination. Additionally, an Avidyne IFD540 was recovered and forwarded to the National Transportation Safety Board (NTSB) Vehicle Recorders Laboratory, Washington, DC, for data download. The engine was further examined at a recovery facility by a representative of the engine manufacturer, under the supervision of an FAA inspector. No issues were identified with the throttle linkage. The examination revealed that the No. 3 cylinder exhaust valve was stuck in the open position; no other anomalies were noted with the airframe or engine. The No. 3 cylinder was then forwarded to the engine manufacturer for metallurgical examination under the supervision of an NTSB investigator. The metallurgical examination revealed rough residues and patches in the valve guide and valve guide material adhered to the exhaust valve stem. Caked residues were observed around the exhaust valve tip. Coked oil deposits appeared to be present in the rocker box around the exhaust valve guide and the cylinder head cooling fins around the exhaust port appeared white around the exhaust port, consistent with heat tinting. Measurements of the exhaust valve guide bore’s inside diameter were all below specification for a new valve guide, and the diametral valve-to-guide clearances were also below specification at the middle and inboard ends of the guide. As of the publication of this report, the engine manufacturer was conducting an internal investigation to address the issue. Download of the Avidyne IFD540 data revealed that no engine data had been stored. Review of maintenance records revealed that the No. 3 cylinder had been operated for about 1,072 hours since it was installed new on December 22, 2021.

Flight

Event TypeAccident
Event Time14:42 EDT
Nearest AirportLagrange-Calloway Airport (0nm N)
Runway21
Runway Length5000 ft
Runway Width100 ft
Flight Plan FiledNone
Flight Plan ActivatedNo
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftPiper PA28 161
Tail NumberN4298V
Aircraft CategoryAir
DamageSubstantial
OperatorAirventures
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsLycoming · O-320 · Reciprocating · 160
Seats4

People & Injuries

Injury Summary2 injuries (2 minor injuries)
Fatal0
Serious0
Minor2
Uninjured0
Total2
Crew 1Age 53 · None · Minor
Crew 2Age 61 · Third Class · Minor

Conditions

ConditionsVMC
LightDaylight
Wind270° @ 3 kt
Visibility10 sm
CeilingBroken clouds 6000 ft
Temperature / Dew Point63 F
Altimeter29.94 inHg
Observation Time14:55
Weather SourceWFAC

Appendix: Source Data