NTSB Factual Report

HISTORY OF FLIGHT

On September 21, 2001, at 1756 central daylight time, a Piper PA-32R-301 single-engine airplane, N192SP, was destroyed when it impacted trees and was consumed by fire following a loss of engine power during takeoff climb from the Waco Regional Airport, Waco, Texas. The airplane was registered to Avex Inc., of Camarillo, California, and operated by the private pilot. The private pilot, who was receiving instrument instruction, and the flight instructor were not injured. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the 14 Code of Federal Regulations Part 91 instructional flight. The local flight departed the McGregor Executive Airport, McGregor, Texas, approximately 1630.

The pilot was receiving instrument instruction and had completed an approach and touch-and-go landing. Following the airplane's take off from runway 19, the Waco Regional Airport air traffic controller heard "a high pitch screaming noise." The controller observed the airplane lose altitude and heard the pilot broadcast a mayday call. Shortly thereafter, the controller heard an emergency locator transmitter signal.

According to the private pilot, the airplane touched down approximately 1/3 down the length of the runway at 70 knots. He retracted the flaps and added power while checking the instruments. He did not notice any warning lights. The airplane was rotated at 80 knots, and a climb was established. The landing gear was retracted and the airplane was trimmed for a 90-knot climb. The pilot noticed that the "engine sounded loud" and thought that his noise canceling headset had malfunctioned. He checked the instruments and noticed that the tachometer was "reading in [a] very abnormal range." He added that the tachometer needle at full power was normally at the 2 o'clock position; however, he noted that the needle was in the 5 to 6 o'clock position. He did not note the other instruments since he started working on a "propeller over speed" situation. The pilot reported that he pulled the propeller control aft approximately 1/4 of the way; however the tachometer gave "very erratic readings." The pilot returned his attention to flying and noticed that the airplane "did not feel like it was climbing right." He added that the engine sounded loud but not rough. The pilot stated that the flight instructor attempted to adjust the power controls; however, there was no change in engine speed. The pilot observed a "light stream of white smoke coming out of the left side of the cowling," and the engine continued to run. The pilot attempted to land near a lake on the south end of the airport; however, they did not have enough altitude. He was not sure if the engine was still operating at that point. The flight instructor made a mayday call after warning the pilot to not stall the aircraft. The airplane then impacted small trees and terrain in a wings level attitude. The pilot secured the airplane before exiting. He added that they were near the tail section (approximately 8 seconds after exiting the airplane) when the airplane "ignited explosively."

The flight instructor reported that "shortly after take off, the student and I heard an unusual sound, and we began to lose aircraft performance although the engine sounded normal." The flight instructor adjusted the propeller and mixture control with no noted change in engine performance. The flight instructor further reported that they did not have time to troubleshoot the problem, and he instructed the pilot through the forced landing.

The FAA inspector, who responded to the accident site, noted that the aircraft was destroyed by the post-accident fire and that the propeller was in a flat pitch. The airplane wreckage was transported to Air Salvage of Dallas, Lancaster, Texas, for further examination.

AIRCRAFT INFORMATION

The 1992-model airplane was equipped with a Lycoming IO-540-K1G5D engine (serial number RL-27528-48A). The airplane was originally type certificated with a Hartzell propeller; however, a McCauley B3D36CA33-C 3-bladed propeller (serial number 000181) was installed on the accident airplane in accordance with McCauley Supplemental Type Certificate (STC) SA433CH. A review of the aircraft maintenance records revealed an endorsement in the propeller maintenance records indicating that the propeller was installed on the aircraft on May 27, 2000, at a tachometer time of 1,329.4 hours. According to the maintenance records, the engine was factory remanufactured and given a zero-time on May 5, 2000, and was installed on the accident airplane on the same day as the propeller installation.

According to Emergency Airworthiness Directive (AD) 2000-18-53, any Lycoming IO-540-K1G5D engine that had been manufactured new, rebuilt, overhauled, or had the oil filter converter plate (part number LW-13904) or gasket (part number LW-13388) replaced, after April 1, 1999, had to comply with the AD. The AD required the replacement of the oil filter converter plate gasket in accordance with Lycoming Service Bulletin (SB) 543A before further flight on engines with more than 50 hours time since new, time since overhaul, or time since the last replacement of the gasket or converter plate, and thereafter every 50 hours time in service since the last replacement of the gasket. The AD was issued after the FAA received reports of certain oil filter converter plate gaskets extruding from the seat of the oil filter converter plate. The protruding or swelling of the gasket was allowing oil to leak from between the plate and the accessory housing. This condition, if not corrected, could result in complete loss of engine oil and subsequent seizing of the engine and possible fire.

A review of Lycoming Service Bulletin SB 543A revealed that Lycoming recommended the replacement of the gasket before further flight, and at each 50-hour oil change thereafter. There was a Supplement No. 1 to SB 543A, which provided an alternate means of compliance by allowing a replacement of gasket part number LW-13388 with a "new" gasket, part number 06B23072. If the "new" gasket was used, the number "543" was to be vibropeaned on the outer surface of the converter plate flange. The SB supplement also indicated that "Service Bulletin 543A affects the Textron Lycoming engines listed under models affected (which included IO-540-K1G5D) only if: 1. They were shipped from the factory between April 1, 1999, and October 4, 2000. 2. They have had the oil filter converter plate gasket field replaced after April 1, 1999, with part number LW-13388. 3. They have had the oil filter converter plate field replaced after April 1, 1999, with part number LW-13904."

Examination of the maintenance records revealed that the aircraft underwent its last annual inspection on June 1, 2001, at an aircraft total time of 1,647.2 hours and a tachometer time of 1,613.5 hours. The engine underwent a 100-hour inspection during the last annual inspection (284.1 hours following the engine remanufacture). According to the 100-hour endorsement, ADs had been "checked through 2001-08. See AD compliance report for details." Review of the AD compliance report supplied by the mechanic revealed that AD 2000-18-53 was not listed on the report as being accomplished. During a telephone interview conducted by the NTSB investigator-in-charge (IIC), the mechanic, who endorsed the last annual and 100-hour inspections, reported that he did not perform AD 2000-18-53 because he came "to the conclusion that it did not apply according to the latest MSB (manufacturer's service bulletin) supplement."

As of September 18, 2001, the aircraft had accumulated a tachometer time of 1,705.6 hours.

TESTS AND RESEARCH

On October 3, 2001, the NTSB IIC and the FAA inspector examined the accident airplane at Air Salvage of Dallas. The NTSB IIC attempted to manually rotate the propeller; however, the crankshaft would not allow rotation. It was noted that the #6 connecting rod had failed and punctured the upper left side of the crankcase between the #6 cylinder's pushrods. The oil dipstick was removed and examined, revealing no evidence of oil. The propeller governor was removed and examined. There was no oil inside the governor and its oil inlet filter was clean and free from debris. The governor shaft was manually rotated and a suction noise was noted through its ports; however, no oil exited the governor ports during shaft rotation. The crankcase was examined for evidence of an oil leak. No oil was noted in the fractured crankcase area or anywhere else on the crankcase. The accessory section was examined. The oil filter was removed and no oil was present and the filter was free from debris. The oil pump pick-up screen was examined and it was free from debris. The oil filter converter plate was removed and examined. It was noted that the oil filter adapter plate gasket sustained heat damage. There was approximately a 3-inch arced section on the converter plate flange and the plate's mating face that did not display remnants of the adapter plate gasket. Close examination of the converter plate revealed that "543" had not been vibropeaned onto its surface; therefore, indicating that SB 543A supplement No. 1 had not been conducted.

The aircraft fuselage was lifted and the bottom side of the fuselage was coated with oil.

ADDITIONAL INFORMATION

The wreckage was released to the owner's representative on November 21, 2001.

NTSB Probable Cause

the mechanic's failure to perform an airworthiness directive, which resulted in the loss of engine oil through a partially failed oil filter converter plate gasket, and subsequent engine failure during takeoff climb. A contributing factor was the lack of suitable terrain for the forced landing.