ATL06LA027
ATL06LA027

HISTORY OF FLIGHT

On December 27, 2005, at 1500 eastern standard time, a Piper PA32-300, N2887M, registered to 373DC LLC, operating as a 14 CFR Part 91 personal flight, had a loss of engine power while climbing through 4,700 feet AGL in the vicinity of Maiden, North Carolina. The airplane collided with the ground during an emergency landing. Visual meteorological conditions prevailed and an instrument flight plan was filed. The airplane received substantial damage. The private pilot and one passenger reported no injuries. The flight originated from Hickory Regional Airport, Hickory, North Carolina, on December 27, 2005, at 1445.

The pilot stated he was in radio contact with Charlotte Approach Control and had received clearance to climb to 5,000 feet. The airplane was climbing through 4,700 feet when the engine quit. The pilot attempted an engine restart without success and informed the controller of the loss of engine power. The controller provided the pilot with the direction and distance to Lincolnton County Regional Airport, Lincolnton, North Carolina, and the pilot turned the airplane towards the airport. The pilot attempted another engine restart without success and observed an open field to his left. The pilot turned the airplane to the left towards the emergency landing area. On final approach, the pilot observed the emergency landing area ran upslope between 15 to 18-degrees with terraces. On touchdown, the airplane collided with a terrace and the airplane rotated 30-degrees to the left separating the left wing.

PERSONNEL INFORMATION

Review of information on file with FAA Airman's Certification Division, Oklahoma City, Oklahoma, revealed the pilot was issued a private pilot's certificate on January 16, 2004, with ratings for airplane single engine land and instrument airplane The pilot's last flight review was conducted on January 15, 2004. The pilot holds a second class medical certificate issued on January 18, 2005, with the limitation "must have available glasses for near vision." The pilot reported on the NTSB Pilot/Operator Aircraft Accident/Incident Report that he has accumulated 295 total flight hours of which 120 hours are in the Piper PA31-300.

AIRCRAFT INFORMATION

Review of airplane logbooks revealed the engine was overhauled by Blue Angel Engines on February 2, 2004, by Wright Airmotive. The tachometer time was 3892.6 hours, and the engine had 0 hours since major overhaul.

On September 4, 2004, the propeller was removed from the engine and a three bladed Hartzell propeller was installed. An entry in the propeller logbook on August 2, 2005, states, "Removed and reinstalled same repaired propeller assembly S/N 023017. Ground run engine and checked for leaks." There is no other entry in the logbook pertaining to a propeller strike or repair. The last recorded annual inspection was conducted on August 2, 2005.

The pilot indicated on the NTSB Pilot/Operator Aircraft Accident/Incident report that the airplane had accumulated 21 hours since the last annual inspection. The airplane was involved in an incident resulting in a forced landing due to a lack of oil pressure in August 2005, and the propeller was removed from the airplane. The engine was removed from the airplane on August 20, 2005, by Carolina Aero Service and transported to Triad Aviation Inc., for disassembly and repair. Triad Aviation Inc. stated they did not have any paperwork regarding the overhaul of the engine or any paperwork pertaining to a propeller strike.

The Engine Shop Supervisor for Triad stated, "Upon receipt of the engine, a visual inspection was performed and it was noted that the crankshaft gear was improper for this engine application. In our opinion, the use of an improper crankshaft gear caused the disengagement of the oil pump drive, thus leading to the failure of the oil pump and eventual failure of the engine. A mud daubers nest was found inside the oil pickup screen (per conversation with Eric Mennis FAA contact for this mishap) this blockage may have caused an increase in pressure on the oil pump, which in turn may have accelerated the eventual engine failure."

Triad Aviation Inc., opened Invoice/Work Order No. 15359 on September 20, 2005, and the work order were completed on October 31, 2005. The work order states in INSTRUCTIONS/WORK DESCRIPTION:

"Disassembled (1) Lycoming IO-540-K1A5 S/N L-11812-48 engine for repairs. Cleaned, inspected, magnafluxed, dye checked and repaired as needed. Replaced parts as listed. Cylinders (1-6) - repaired as needed, cleaned, inspected, refaced seats and valves, honed barrels, lapped and leak checked - ok. Crankshaft - S/N 149296-1 magnafluxed, inspected, ground rods and mains M003, renitrided, cadium plated, baked flange, repaired per SI 1111, rebushed ctwt blades. Reassembled engine IAW Lycoming Manual and FAA Regulations. AD2004-10-14 correction - prevent loosening or failure of the crankshaft gear retaining bolt/C/W per SB 475C.

Test Run Engine
Test ran engine 2 hours 15 minutes, RPM 2700, oil pressure 80 lbs, oil temperature 201 degrees, CHT 354 degrees, mag check at 2100 RPM, L 100 RPM, R 100 RPM. Compression test cylinder #1 76/80 #2 76/80 #3 78/80 #4 76/80 #5 76/80 #6 76/80.

This engine and/or component is approved for return to service. All pertinent details on file this repair station. TRIAD AVIATION, INC. FAA REPAIR STATION # PP4R448M.
Signed:_____________________________Date: 10/31/05."

Lycoming Mandatory Service Bulletin No. 475C states, that crankshaft gear modification and assembly procedures are required during overhaul, after a propeller strike, or whenever crankshaft gear removal is required. Air Worthiness Directive (AD) 2004-10-14 C was effective on June 25, 2004. This AD results from a change to definition of a propeller strike or sudden stoppage. The actions specified in the AD are to prevent loosening or failure of the crankshaft gear-retaining bolt, which may cause sudden engine failure.

AD 2004-10-14 was effective on June 28, 2004. The AD removes the requirement to perform inspections at overhaul and during repair of the gear train, because Lycoming has incorporated those procedures from their Service Bulletin into their Overhaul Manual. Triad Aviation was asked why they referenced AD 2004-10-14 in the sign off of the work performed on Work order No. 15359. Triad stated, "Triad, as a matter of course, signs off AD 2004-10-14C when it performs Lycoming SB 475C. The "C" was inadvertently omitted when the work order was filled out."

The engine and propeller were reinstalled on the airplane on November 18, 2005, at tachometer time 4198.3 hours.

Review of Carolina Aero Service, LLC Invoice No. 831 dated November 21, 2005, states "Labor to remove fuel injection system, purge water and reinstall. Precision Service Bulletin No. PRS-97 states in paragraph 2. "Accomplishment Instructions D. A complete overhaul is mandatory regardless of any FAR operational category when the injector or fuel system component has been subjected to a severe environment such as but not limited to:...(2) Contaminated fuel such as water, rust, sand, etc."

METEOROLOGICAL INFORMATION

The Charlotte Douglas International Airport, Charlotte, North Carolina, 1451 surface weather observation was: wind variable at 4 knots, visibility 10 miles, few clouds at 2,500 feet, temperature 61 degrees Fahrenheit, dew point temperature 21 degrees Fahrenheit, and altimeter 29.95.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located in a horse pasture adjacent to 4031Herter Road, Catawba County, in the vicinity of Maiden, North Carolina. The FAA conducted the on scene examination of the airplane. The Hobbs time at the time of the accident was 427 hours. The airplane was equipped with an electronic tachometer. The estimated tachometer time was 4216.9 hours.

USAIG Insurance Company contracted Extreme Aviation, Advance, North Carolina, to recover and store the airplane wreckage pending the NTSB investigation. The airplane wreckage was recovered on January 2, 2006. Follow up examination of the engine assembly and accessories were conducted by the FAA and NTSB Parties to the investigation on January 12, 2006.

The engine assembly was removed from the airframe, bolted to an engine stand and examined. The engine oil had been drained and the propeller, both magnetos, sparkplugs, oil cooler, vacuum pump, and exhaust had been removed. All three-propeller blades were curled aft 45 degrees at midspan and exhibited chord-wise paint scuffing of the propeller tips.

The accessory drives did not rotate as the engine was rotated. Visual inspection of the accessory case through the magneto-mounting hole revealed about 1/8 inch of the crankshaft gear bolt shank was visible above the surface of the crankshaft gear. The bolt had been unable to back completely out of the crankshaft gear due to the gear remaining engaged to the oil pump drive shaft. The locking plate, Part Number: LW-18638 was not present on the crankshaft gear attaching bolt, and the locking plate was not listed as installed among the parts detailed on Work Order No. 1539. The Triad Aviation Inc., build up sheet was initialed on page 3, "Engine assembly and Inspection, Description, 8 "Crankshaft Gear Bolts Torqued and Safetied (torque 204 in-lbs)." Instructions for the assembly of the crankshaft gear, gear bolt and lockplate to the crankshaft are provided in the Lycoming Mandatory Service Bulletin No. 475C and in Chapter 7 of the Lycoming Direct Drive Engine Overhaul Manual.

The crankshaft gear bolt was lifted out of the crankshaft gear and the gear was lifted off of the end of the crankshaft. The crankshaft gear bolt was fractured about 1/4 inch below the top thread. The end of the remaining threaded portion was visible in the crankshaft bolt hole. The portion of the crankshaft dowel, which is normally engaged in the crankshaft gear, was separated and found lying on the end of the crankshaft. The end of the remaining portion was visible in the crankshaft dowel hole.

All engine cylinders were removed and were not damaged. The oil sump was removed and the crankcase parting surface fasteners were removed. The nut on the bottom aft bolt inside the oil sump was found safety wired but the bolt was loose in its hole. The safety wire securing the oil pump nuts were removed. The nuts were not tight on the studs and was removed using finger pressure.

The oil filter element was removed and contained a quantity of cooper colored flakes. The oil suction screen was removed and contained a quantity of copper colored flakes and several metallic balls about 1/8 inch in diameter. All sparkplugs were examined and were dark gray in color and the electrodes exhibited a "worn normal" condition when compared to the Champion Aviation Check-A-Plug Chart.

The crankcase halves were separated and the camshaft and lifters were unremarkable. The rear main bearing shell and corresponding crankshaft journal were heavily scored and discolored. The crankshaft bearing dowels were loose in the crankcase and the holes were elongated. The corresponding holes in the bearing shells were elongated.

The crankshaft, crankshaft gear and bolt, rear main bearing shells and debris from the oil suction screen were forwarded to the NTSB Material Metallurgy Laboratory for further examination. Examination of the gear-retaining bolt revealed the bolt was fractured through the threaded portion of the shank about 1.35 inches from the head. The fracture surfaces were heavily damaged by post separation mechanical contact between the fracture faces. The fracture features in these areas were typical of fatigue progression through the bolt cross section. The aft face of the crankshaft gear displayed a lighter shaded shadow. The shadow had a roughly hex shape that approximated the shape and size of the head on the gear-retaining bolt. The exemplar lockplate was roughly oval in shape.

The aft piece of the locating dowel was fractured and the plane of the fracture was adjacent to the shoulder on the dowel. Magnified inspections revealed fracture traces, ratchet marks and other topographic features indicative of multiple origin fatigue initiation and propagation. The magnified inspections indicated that the shoulder of the dowel was approximately flush with the crankshaft surface. Service Bulletin 475C (SB) requires the dowel to be driven into the crankshaft so that the shoulder is located between 0.010 and 0.020 inch below the surface, as displayed in the illustration of figure 8 (B) taken from SB 475C.

The aft face of the crankshaft gear and the forward face of the gear displayed wide spread matching fretting regions. In addition, a wear / contact ring was visible on the gear face around the dowel hole. The diameter of the contact ring was consistent with the larger diameter of the dowel shoulder.

The No. 5 main bearing journal and bearing shells were severely worn and gouged. The journal surface was circumferentially gouged across its entire width, with attendant heat tinting of the journal and adjacent surfaces. Macro etching of a rough ground cross section through the crankshaft revealed lighter etching regions adjacent to the journal surface consistent with overheating of journal surface.

The bearing also showed similar gouging and damage on the inner surfaces. Some copper colored bearing material was visible on the surfaces but measurements indicated that little or no thickness of bearing material remained on the steel backings. The outer surfaces of the bearing shells were slightly heat darkened and the oil portholes were circumferentially elongated. Flakes and small sheets of bearing material were recovered from the oil sump. Several of the flakes were deformed with a radius characteristic of material extruded from the bearing past the journal radius.

MEDICAL AND PATHOLOGICAL INFORMATION

The NTSB and local law enforcement personnel requested no toxicology specimens from the pilot.

ADDITIONAL INFORMATION

The airplane wreckage and components were released to an USAIG Insurance adjuster on June 27, 2006.



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