Accident Details
Probable Cause and Findings
The pilot's failure to attain a proper touchdown point following a loss of engine power and his inability to stop the airplane on the short, soft runway. Contributing to the accident was the inadequate maintenance of the airplane by the owner and the mechanic and the improper annual inspection by the mechanic.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn March 25, 2017, about 1530 central daylight time, a Piper PA-28-140, N4329T, impacted a fence and pond during a landing overrun on runway 18 at Burg Lake Aero Airport (30TX), Stonewall, Texas. The commercial pilot received fatal injuries, and the airplane sustained substantial damage. The airplane was owned by the pilot and his brother and operated by the pilot under Title 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Day visual meteorological conditions prevailed at the time of the accident and no flight plan had been filed. The flight originated from 30TX about 1525 and was destined to New Braunfels Regional Airport (BAZ), New Braunfels, Texas, but returned to 30TX.
The accident flight was the airplane's first flight after its annual inspection and the replacement of one of the fuel pumps. The pilot's brother-in-law stated that the pilot performed a full-power run-up, which was "okay.". The airplane engine cowl was then put back onto the airplane, and the pilot fueled the airplane from the airport fuel tank to a level that was at the fuel tank "tabs." The pilot then performed another engine run-up at full power near the approach end of the runway 18. During the takeoff, the airplane was not more than 10 ft above the runway when it was at about half down the length of the runway. The brother-in-law thought the airplane was going to hit trees located near the departure end of the runway. The airplane had been gone for about 5-10 minutes before it returned to airport. The brother-in-law reported that the airplane touched down about halfway down the runway, and it was "going way too fast." He thought that the pilot never increased engine power after the airplane touched down and that the engine power was at idle during the landing but was "not sure" because he was in his hangar, and the airplane does not produce much engine noise at idle.
A witness who was driving westbound toward Stonewall, Texas, saw an airplane descend toward the 30TX runway. He said the airplane was "way too high," and its approach was "pretty steep." He said that he thought to himself that the airplane was "not going to make it." He stated that he was in his truck with the windows closed and could not hear the airplane engine.
The airplane overran the departure end of the runway during the landing, went through a barbed wire fence, and into a pond. PERSONNEL INFORMATIONAccording to the pilot's logbook, his last flight entry was a flight review in a Piper PA-28R-200 on December 21, 2016; the duration was 1.1 hours. The entry did not have a flight review endorsement by the flight instructor who provided the review.
The Federal Aviation Administration (FAA) had no record of any previous accidents, incidents, or enforcement actions for the pilot. The pilot's brother-in-law stated that the pilot had previously landed at the airport "several times" because the airplane received 2 or 3 annual inspections at 30TX.
The mechanic held an airframe and powerplant mechanic certificate with inspection authorization, which was renewed on March 17, 2017, by an FAA inspector from the San Antonio flight standards district office (SAT FSDO). The FAA had no record of any previous enforcement actions against the mechanic. AIRCRAFT INFORMATIONThe 1971-model-year Piper PA-28-140 (Cherokee) airplane was purchased by the pilot and his brother on November 3, 2010, and the aircraft registration was accepted on February 9, 2011
The airplane was powered by a Lycoming O-320-E3D, serial number L-46554-27A, case number 4865, engine that underwent its last overhaul by the engine manufacturer dated June 29, 1988, at an engine total time of 1,945.45 hours. The engine underwent its last overhaul, which was performed by an airframe and power plant mechanic, dated May 29, 1998, at an engine total time of 2,991.8 hours and a tachometer time of 4,236.2 hours.
The Hobbs meter and tachometer indications at the accident site were 889.5 hours and 5,063.7 hours, respectively.
According to an airframe and powerplant mechanic, the pilot called him at the end of February 2017 to schedule an annual inspection of the airplane. The pilot did not report any issues and said that the airplane had been flying "beautifully." On the day of the inspection, March 4, 2017, the mechanic arrived and the airplane was at 30TX and the airplane was already "opened up." The pilot reported that the airplane was having occasional fuel pressure problems. Upon completion of the inspection, the airplane was towed outside, started easily, and the engine was run for about 10 minutes. The mechanic stated that the engine was running "satisfactorily," and he signed off the logbooks.
According to an FAA inspector from the SAT FSDO, the mechanic, who signed off the annual inspection, stated that he watched but did not work on the airplane. The mechanic and the pilot used an inspection checklist that was not the inspection checklist in the Piper Cherokee Service Manual. It is unknown if the mechanic or the pilot used the Piper Cherokee Service Manual during the inspection of the airplane.
Since 2011, all of the annual inspections, which were performed every year, were signed by the mechanic that had signed off the annual inspection.
Lycoming Service Instruction No. 1009AZ stated, in part:
Engine deterioration in the form of corrosion (rust) and the drying out and hardening of composition materials such as gaskets, seals, flexible hoses and fuel pump diaphragms can occur if an engine is out of service for an extended period of time. Due to the loss of a protective oil film after an extended period of inactivity, abnormal wear on soft metal bearing surfaces can occur during engine start. Therefore, all engines that do not accumulate the hourly period of TBO specified in this publication are recommended to be overhauled in the twelfth year.
A review of the engine and airframe logbooks revealed that the magnetos, exhaust, fuel and oil lines, and carburetor had not been replaced/overhauled since the engine's last overhaul in 1998.
The Piper Cherokee Service Manual states that a 100-hour inspection is a complete inspection of the airplane, identical to an annual inspection. The manual stated to replace the engine flexible hoses (fuel, oil, etc.) as required but not to exceed 1,000 hours time-in-service, 8 years, or engine overhaul, whichever comes first; no fluid hose may exceed 20 years time-in-service.
The Airplane Flight Manual (AFM) provided landing distance versus density altitude information for the only the following conditions: flaps 40°; power off; paved, level runway; no wind; maximum braking; short field effort; and airplane gross weight of 2,150 lbs. Based upon a density altitude of 1,535 ft, the landing distance at gross weight was about 550 ft, and the landing distance over a 50-ft obstacle was about 1,100 ft. METEOROLOGICAL INFORMATIONBased upon the 1535 recorded weather, the density altitude was about 1,314 ft. AIRPORT INFORMATIONThe 1971-model-year Piper PA-28-140 (Cherokee) airplane was purchased by the pilot and his brother on November 3, 2010, and the aircraft registration was accepted on February 9, 2011
The airplane was powered by a Lycoming O-320-E3D, serial number L-46554-27A, case number 4865, engine that underwent its last overhaul by the engine manufacturer dated June 29, 1988, at an engine total time of 1,945.45 hours. The engine underwent its last overhaul, which was performed by an airframe and power plant mechanic, dated May 29, 1998, at an engine total time of 2,991.8 hours and a tachometer time of 4,236.2 hours.
The Hobbs meter and tachometer indications at the accident site were 889.5 hours and 5,063.7 hours, respectively.
According to an airframe and powerplant mechanic, the pilot called him at the end of February 2017 to schedule an annual inspection of the airplane. The pilot did not report any issues and said that the airplane had been flying "beautifully." On the day of the inspection, March 4, 2017, the mechanic arrived and the airplane was at 30TX and the airplane was already "opened up." The pilot reported that the airplane was having occasional fuel pressure problems. Upon completion of the inspection, the airplane was towed outside, started easily, and the engine was run for about 10 minutes. The mechanic stated that the engine was running "satisfactorily," and he signed off the logbooks.
According to an FAA inspector from the SAT FSDO, the mechanic, who signed off the annual inspection, stated that he watched but did not work on the airplane. The mechanic and the pilot used an inspection checklist that was not the inspection checklist in the Piper Cherokee Service Manual. It is unknown if the mechanic or the pilot used the Piper Cherokee Service Manual during the inspection of the airplane.
Since 2011, all of the annual inspections, which were performed every year, were signed by the mechanic that had signed off the annual inspection.
Lycoming Service Instruction No. 1009AZ stated, in part:
Engine deterioration in the form of corrosion (rust) and the drying out and hardening of composition materials such as gaskets, seals, flexible hoses and fuel pump diaphragms can occur if an engine is out of service for an extended period of time. Due to the loss of a protective oil film after an extended period of inactivity, abnormal wear on soft metal bearing surfaces can occur during engine start. Therefore, all engines that do not accumulate the hourly period of TBO specified in this publication are recommended to be overhauled in the twelfth year.
A review of the engine and airframe logbooks revealed that the magnetos, exhaust, fuel and oil lines, and carburetor had not been replaced/overhauled since the engine's last overhaul in 1998.
The Piper Cherokee Service Manual states that a 100-hour inspection is a complete inspection of the airplane, identical to an annual inspection. The manual stated to replace the engine flexibl...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# CEN17FA139