Landing / Ground Loss of Control · NTSB CEN15LA318

PIPER PA38 - 112 — Millbury, OH

1 fatal High-time pilot
DateJuly 25, 2015
LocationMillbury, OH
AircraftPIPER PA38 - 112
Purpose of flightPersonal
ConditionsDay · Visual Meteorological Cond
Phase / occurrenceLanding-flare/touchdown Collision with terr/obj (non-CFIT)
Pilot age67
Pilot total time1,103 hrs · Experienced
Time in typeUnknown
Fatalities1

Probable cause

A loss of engine power due to three of the engine valve adjustment mechanisms backing out, which resulted from improper maintenance.

NTSB findings

  • Aircraft-Aircraft power plant-Power plant-(general)-Incorrect service/maintenance - C
  • Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot

What happened

Shortly after takeoff, the pilot declared a "mayday" and reported to air traffic control that he needed to return to the airport. The airplane crashed in an open field about ½ mile from the airport. The pilot initially survived the accident but later died from his injuries. A postaccident examination of the engine revealed the valve adjustment mechanisms (jam nut and screw) on two of the intake valves and on one of the exhaust valves were backed off. The valve spring retainer on one of the intake valves was broken, and two of the cylinder head gaskets were compromised. The spark plugs were fouled. Given the postaccident condition of the engine, the pilot most likely was returning to the airport due to a loss of engine power. Maintenance records show the engine had an annual inspection about 25 flight hours before the accident. The condition of the valve adjustment mechanisms suggests that either the tappet adjustment was not checked, as recommended by the manufacturer, or the torque on the jam nuts was incorrect.

An editorial "what led to it / how to avoid it" analysis for this accident is generated separately and will appear here.

View the official NTSB docket →