NTSB Factual Report

HISTORY OF FLIGHT

On April 17, 1993, at 1521 eastern daylight time, N56430, a Piper PA-28-140, operated by International Aviation, Inc. of Frederick, Maryland, impacted power lines and was destroyed while attempting a precautionary landing near Lee Airport in Edgewater, Maryland. The pilot was fatally injured and the passenger was seriously injured. Visual meteorological conditions prevailed and no flight plan was filed. The personal flight was conducted under 14 CFR 91 and originated from Frederick, Maryland, en route to Ocean City, Maryland.

At 1148 on the day of the accident, a gentleman identifying himself as the pilot of N56430 contacted the Leesburg Flight Service Station and requested a weather briefing for Hagerstown, Pennsylvania, and Ocean City, Maryland. According to the father of the pilot, the pilot and a friend had decided to fly to Ocean City, Maryland, for the day.

At 1454, the pilot contacted Baltimore Approach Control and reported that he had "... just departed Frederick..." and requested a clearance through the Terminal Control Area at 3,000 feet. Baltimore Approach Control verified that they had the airplane on radar and granted a clearance.

At 1515, the pilot contacted Baltimore Approach Control to report "...we have a problem here...we got partial power..." and requested to "...turn it into Baltimore..." The airplane was about 3000 feet mean sea level (msl) and 12 miles south of Baltimore at the time. The pilot also reported "...we have full tanks." Approach Control provided priority handling to the airplane and a vector to the Baltimore Washington International Airport.

AT 1516, the pilot asked Baltimore Approach Control if he was closer to Lee Airport. Baltimore Approach Control said "affirmative" and the pilot requested vectors to Lee Airport. The airplane was five miles north of Lee Airport at this time. At 1518, the pilot reported that he had Lee Airport in sight and he was going to "...go ahead and make an approach..." At 1519 the pilot changed frequencies to the common traffic advisory frequency (CTAF) for Lee Airport.

A certified flight instructor (CFI) who was at the airport at the time received a phone call from Baltimore Approach Control and was informed about the aircraft. The CFI stated that he utilized a hand-held radio receiver and went outside to see and hear the airplane. He witnessed the accident and said;

"The plane entered the airport environment at the approach end of runway 30 and established a left downwind for runway 12. I questioned the pilot's decision...since the winds were a stiff steady 12 to 15 knots at 300 degrees directly favoring runway 30. Just at that time a call came over the multicom frequency that stated; "Lee Traffic, Lance 56430 will be making [an] emergency partial power landing, will be landing downwind on runway 12". I stated to Greg 'well he knows what he is up against.' The plane then turned a tight left base followed by a turn to final approach for runway 12.

"The plane...began dissipating the excess altitude. As the plane approached the runway 12 threshold, the pilot recovered from the full slip at 30 feet [above the ground] from the runway surface. As the plane straightened the plane's ground speed increased notably.... As the plane traveled down the runway in flight, its height had reached 5 to 10 feet above the runway surface, never touching [the runway]. It was apparent to me that the plane was going to run off the runway and hit the fence at the departure end of runway 12 after landing.... The plane was located two-thirds to three-quarters down the runway...a call came over the multicom frequency; 'Lance 56430 going around runway 12 at Lee'. With steady power, the plane continued climbing and gained altitude.... We both saw the plane bank left. The bank angle reached approximately 50 to 55 degrees and the plane dropped sharply.... I would have to estimate that the plane was about 200 feet [above the ground] prior to banking."

Another witness, who was employed as a police officer and was also a CFI, observed the airplane as it began to go around. He stated that he heard the engine running rough. He saw the airplane turn back toward the airport, descend, impact power lines with its left wing, explode into flames, roll inverted, and impact a corn field located about one quarter mile north of the airport.

The accident occurred during the hours of daylight at 38 degrees 56.57 minutes North and 076 degrees 34.13 minutes West.

PERSONNEL INFORMATION

According to FAA records, the pilot, age 23, was a certificated private pilot with a rating in airplane single engine land. He received his private pilot license on November 28, 1992. He held a current third class medical certificate. According to the pilot's personal logbook, the pilot accumulated about 75 hours of total flight time, including eight hours in type.

AIRCRAFT INFORMATION

The airplane, a 1973 Piper model PA-28-140, was operated as a lease-back rental airplane by International Aviation, Inc., a fixed-based operator located in Frederick, Maryland. According to maintenance logbooks, the airplane had accumulated about 3,600 hours of total flight time. It received a 100-hour inspection on January 29, 1993, and had accumulated about 89 flight hours since the last inspection to the time of the accident. No discrepancies which would have been related to the accident were recorded in the logbooks.

The engine, a Lycoming model O-320-E3D, serial number L30961A27, was originally installed on the accident airplane upon the airplane's delivery from the factory. According to maintenance logbooks, the engine had accumulated about 3,600 hours of total operation, including about 1,600 hours since its last major overhaul. The maintenance logbooks indicate that this overhaul occurred on November 10, 1977, and new exhaust valves, part number 75068, were installed at this time.

METEOROLOGICAL CONDITIONS

The reported surface weather conditions at the Baltimore Washington International Airport about 30 minutes prior to the accident were: "measured ceiling 7,000 feet overcast, visibility 20 miles, temperature 56, dewpoint 33, wind 290 degrees at 16 knots gusting to 22 knots, altimeter 29.84." The Baltimore Washington International Airport is located about 15 miles north of Lee Airport.

The reported wind conditions at the Baltimore Washington International Airport were consistent with the observations given by the two CFI ground witnesses at Lee Airport.

AERODROME INFORMATION

Lee Airport is located about five miles southwest of the city of Annapolis, Maryland. It is uncontrolled and rests at an elevation of 30 feet msl. It has a single asphalt runway which is 2,505 feet in length and 45 feet in width. The runway is oriented 12/30. The approach end of runway 30 is about one-quarter mile from a four-lane state highway. Several restaurants and power lines are located along this highway. The approach end of runway 12, the accident runway, is located near an open field. The airport has a wind sock located near the center of the airport.

WRECKAGE AND IMPACT INFORMATION

The airplane wreckage was examined at the accident site by an FAA inspector on the day of the accident, April 17, 1993. The inspector authorized the removal and security of the wreckage to a hangar prior to the Safety Board's arrival. The wreckage was then examined by the Safety Board on the evening of the accident, and again on the following day.

The wreckage was found about one-quarter of a mile southeast of Lee Airport. The airplane came to rest inverted in a plowed filed. A broken power line was found about 150 feet from the accident site. The airplane remained in one piece. The cabin area was crushed and damaged by fire. Both wings and the vertical stabilizer were substantially damaged.

The right wing fuel tank was compromised and received thermal damage. The left fuel tank was not compromised and was almost full with a liquid having the same color, smell, and texture of 100 low lead aviation fuel.

Control cable continuity for all flight controls was verified. The flaps were found in the 25 degree extended position.

During the inspection of the cockpit, the ignition switch was found in the RIGHT magneto position. The carburetor heat control was found in the ON position.

The engine and propeller remained attached to the airframe. The propeller exhibited no evidence of chordwise scratching or torsional damage. About seven quarts of oil were found in the engine. All engine accessories were inspected and no mechanical malfunctions were found. Both magnetos were removed, spun, and produced a spark on all leads.

The propeller was able to be turned about 270 degrees before binding. After removal of the no. 4 bottom spark plug, three foreign metallic objects were found inside the no. 4 cylinder assembly. The intake and exhaust manifolds surrounding the no. 4 cylinder were then removed. Further inspection inside the cylinder revealed that the no. 4 exhaust valve stem had separated; part of the valve stem remained inside the exhaust valve guide. The no. 4 cylinder assembly was then removed. Another metallic object was retrieved. The no. 4 piston face exhibited signs of gouging damage. The no. 4 cylinder assembly, including the exhaust valve head, piston, and the four metallic objects were taken to the Metallurgical Laboratory of the Safety Board for further analysis.

MEDICAL AND PATHOLOGICAL INFORMATION

The autopsy of the pilot was performed by Dr. Ann Dixon at the State of Maryland Medical Examiners Office, Baltimore, on April 17, 1993. The autopsy revealed that the cause of death was "chest injuries and positional asphyxia."

A forensic toxicology was performed on specimens taken from the pilot by the FAA Civil Aeromedical Institute. The results of this toxicology were negative for drugs, alcohol, carbon monoxide, and cyanide.

TESTS AND RESEARCH

The no. 4 cylinder assembly and four pieces of the broken exhaust valves were examined by the Materials Laboratory Division of the Safety Board. A report of the examination was completed on June 21, 1993, and is attached

According to the report:

"Examination of the surface of the liberated stem revealed the part number identification markings "75068" in the area above the valve spring retainer groove.

"The exhaust valve was of a hollow stem type. Visual examination showed that it fractured through the transition region between the head and the stem, about 0.35 inch below the underside of the head.... In addition, multiple radial cracking was evident on the periphery of the head pieces.

"Significant damage to the fracture surface was also found on the stem portion of the valve.... Both fracture surfaces were covered with heavy accumulation of exhaust deposits.

"Further examination of this surface disclosed ratchet marks and a faint crack arrest positions.... Both of these fractures are indicative of fatigue cracking.

".... No evidence of a chrome plate was observed on the outer diameter surface. According to Textron Lycoming, the stem of the valve in the area that fits inside the valve guide should be chromium plated with place thickness between 0.0002 inch and 0.0004 inch.

"A representative of Textron Lycoming indicated that the specified outside diameter of the stem in a new valve is between 0.4938 inch and 0.4945 inch. Measurements indicated that the diameter of the accident valve areas where it was inserted into the valve guide was between 0.4925 and 0.4935, which is lower than specified."

ADDITIONAL INFORMATION

Two service bulletins concerning exhaust valves that are pertinent to this accident were issued by Textron Lycoming. The first, Service Bulletin No. 404, was issued on September 17, 1976, about one year prior to the major overhaul of the accident engine. The service bulletin addressed the inspection of exhaust valves on "All low compression 80/87 rated O-320-A, E, IO-320-E, AEIO-320-E, and O-540-B series engine since new, remanufactured, or overhauled using P/N 75068 exhaust valves." The bulletin also stated: "During engine overhaul, it is recommended that no. 74541 exhaust valves are installed instead of no. 75068 valves."

A review of engine maintenance logbooks of N56430 revealed that exhaust valve part no. 75068 was installed on the engine when it received its only major overhaul.

The second service bulletin, No. 388B, was issued May 13, 1992. The subject of this bulletin was "Procedure to Determine Exhaust Valve And Guide Condition." The "Time of Compliance" section states: "Helicopter engines should be inspected at 300 hour intervals; all other engines should be inspected at 400 hour intervals, or earlier if valve sticking is suspected."

A review of the engine maintenance logbooks of N56430 did not reveal any specific record of compliance with this service bulletin.

The aircraft wreckage was released to Mr. Charles Bowman, insurance adjustor for Peter J. McBreen and Associates, Inc., on April 20, 1993.

NTSB Probable Cause

The pilot's improper in-flight planning/decision after selecting the wrong runway for a precautionary landing , which resulted in an inadvertent descent into transmission lines, while attempting to maneuver back to the runway. Factors related to the accident were fatigue failure of the number 4 exhaust valve, and failure of maintenance personnel to comply with service bulletins regarding the inspection and replacement of the valve.