ROSWELL, GA, USA
N8554C
Piper PA-32R-300
While transiting the Atlanta area, the commercial rated pilot reported a sudden loss of engine oil pressure and a subsequent severe vibration to Atlanta Approach Control. Approach Control vectored the flight toward the Dekalb-Peachtree airport for an emergency landing. Due to the loss of power, the pilot was unable to maintain altitude and was force landed on a highway. The pilot left the airplane in the cruise configuration and landed with wheels and flaps retracted. Upon landing, the aircraft slid on the road contacting a Jeep Cherokee, then impacting a Mazda 626. After the impact with the Mazda, the aircraft and the automobile caught fire destroying both. The pilot received serious injuries while the driver of the automobile was fatally injured. During a post crash disassembly of the engine, the number five connecting rod was found fractured through the rod shoulder. A metallurgical examination of the connecting rod was performed, during which the #5 rod was found to have fatigue cracks originating at or near areas of galling. Connecting rods are routinely re-used following inspections for evidence of galling. The engine had operated to within about 60 hours of its recommended time between overhauls, with the broken rod installed.
HISTORY OF FLIGHT On October 28, 1998, approximately 1824 eastern standard time, a Piper PA-32R-300, N8554C, operated by Air Carriers, Inc. as Fastcheck 330, collided with two private vehicles during a forced landing in Roswell, Georgia. The airplane was operated under the provisions of 14 CFR Part 135, and instrument flight rules (IFR). An IFR flight plan was filed for the on-demand, domestic, cargo flight. Visual meteorological conditions prevailed. The commercial pilot received serious injuries, and the airplane was destroyed during a post crash fire. Fatal injuries were sustained by the driver of one the private vehicles. The flight originated from Bessemer, Alabama, approximately 1630, and was destined for Gainesville, Georgia. The purpose of the flight was to transport a cargo of bank checks. According to the pilot, she loaded the airplane through the rear cargo door, and used a cargo net to retain the cargo. A bathroom scale was used to weigh the cargo. The pilot did not know if the scale was calibrated, however, it was equipped with an adjustment wheel in order to zero the display. Prior to departure, a run-up check was performed. The pilot stated that both magnetos performed within limits, and the propeller was cycled with no discrepancies. A check of both the suction gauge and enunciator lights produced satisfactory results. After takeoff, the airplane climbed to 5,000 feet. According to the pilot, the weather during the flight was clear, with greater than 6 statute miles visibility. While in contact with Atlanta Air Traffic Control (ATC), and approximately 12 miles north of the Dekalb-Peachtree Airport (PDK), the pilot reported a severe vibration in the airplane. She advised ATC that all gauges were "in the green" except for the oil pressure indicator. That gauge was off scale, displaying no oil pressure. The pilot noted that when she reduced power to begin her descent, the engine vibration decreased. After declaring an emergency to ATC, the pilot requested to be directed to the nearest airport. ATC indicated the airplane would be vectored toward PDK, and that there was a smaller grass strip about eight miles away. The controller said he was not sure of its location. The pilot requested information about the terrain beneath her and was advised of an interstate highway. She reported that the highway had bumper to bumper traffic and stated she did not want to land on the freeway. The pilot was advised to maintain heading and altitude, as best she could, and that a Lockheed C-130 Hercules would be following her in order to track her location. The pilot informed ATC that she was going down. The pilot provided the following information regarding her actions after reporting the severe vibration to ATC. She attempted to maintain altitude but was unsuccessful due to the reduced engine power. She added power in attempts to maintain an altitude of 2,000 feet, but was concerned about the engine falling from the airplane due to the severe vibration. At that point, the pilot stated she committed to the freeway and was able to discern dark spots in between vehicle tail lights. In attempts to maintain performance, she elected to leave both the landing gear and flaps in the retracted positions, and was able to maintain control of the airplane until impact with the highway. The pilot reported that she did not turn off any switches or selectors prior to impact. One witness observed blue colored smoke stream out from the forward section of the undercarriage. Other witnesses reported hearing the engine sputter, and saw the airplane pitch nose down suddenly, just prior to impact with the highway. After impact, witnesses observed the airplane slide along the highway colliding with the center median wall and two vehicles. The first vehicle, a Daimler-Chrysler Jeep Cherokee, was hit in the rear and forced off the highway, resulting in minor damage to the Jeep. The airplane then continued to travel down the highway hitting a Mazda 626. Witnesses observed the airplane pin the Mazda up against the median wall, and both slid under a highway overpass. At 1824 the C-130 reported to ATC that the airplane had landed on the interstate and that the airplane was on fire. The pilot exited from the burning airplane receiving serious injuries. The sole occupant of the Mazda did not exit, and received fatal injuries. Both the airplane and the Mazda were destroyed in the resultant fire. PERSONNEL INFORMATION According to Federal Aviation Administration and the operator's records, the pilot held a commercial pilot certificate with airplane single engine, multi engine, and instrument ratings. Additionally, she held a flight instructor's certificate with airplane single engine land rating. She was issued a first class medical certificate on February 23, 1998. The operator's pilot records indicated the pilot had received a satisfactory competency/proficiency check on September 17, 1998, in the accident airplane. Under remarks, on the check form, the pilot was approved to use lower than standard minimums for takeoff. Pilot in command qualifications, as documented by the operator at the time of the pilot's initial hiring, were compared with 14 CFR Part 135.243, which requires that a pilot in command must have certain flight times in order to be hired by a Part 135 operator. These requirements as stated in Part 135.243( c ) (2) are as follows: "...has had at least 1,200 hours of flight time as a pilot, including 500 hours of cross country flight time, 100 hours of night flight time, and 75 hours of actual or simulated instrument time, at least 50 hours of which were in actual flight...." According to the pilot's logbook, she had accrued the following hours at the time of initial hiring: 1,393.5 hours flight time as a pilot, 693.3 hours of cross country flight time, 114.3 hours of night flight time, and 166.7 hours of actual or simulated instrument time, with 24.6 actual instrument flight hours Title 14 CFR Part 135.247, Pilot Qualification - Recent Experience, was reviewed along with the daily flight records for the week prior to the accident. The pilot had made three takeoffs and landings to meet the requirements for day and night flights. The daily flight records mentioned previously were also compared to 14 CFR Part 135.267, flight time limitations and rest requirements: unscheduled one- and two-pilot crews; it was found that the pilot had been given the proper amount of rest and off-duty time. A review of the initial and recurrent testing of this pilot was compared with Part 135.293 and no omissions were noted. The training manual for this pilot was compared to Part 135.293 and no irregularities were discovered. Additional pilot information is contained on page three of this report under the heading First Pilot Information. AIRCRAFT INFORMATION N8554C, a Piper PA-32R-300, serial number 32R-7680122, was registered to and operated by Air Carriers, Inc. According to the operator's records the airplane was manufactured in 1976. The operator's records reflected that as of October 28, 1998, the airplane had 9,468.8 total flight hours. The last annual inspection was conducted on August 12, 1998, using a Piper inspection checklist. The manufacturers suggested engine time between overhauls was 2,000 hours. According to the operator's records, the engine overhaul was due at 9,531.6, and it had 1,937.2 hours since the last overhaul. Total engine hours were 3,933.3. A weight and balance sheet was found in the airplane records indicating the airplane was last weighed on July 9, 1997. The airplane was last fueled on October 27, 1998, at Bessemer, Alabama, with 42.2 gallons of 100LL aviation gasoline, which filled the fuel tanks to capacity. The airplane records indicated that on October 2, 1998, the altimeter and transponder were inspected and certified in accordance 14 CFR Part 91.411 and 91.413, for flight under instrument flight rules. The emergency procedures section of the Pilot Operating Handbook contained the following procedure for POWER OFF LANDING-GEAR UP LANDING: For gear up landing , proceed as follows when committed to landing: Ignition Off Master Switch Off Fuel selector Off Mixture idle cut-off Seat belt and harness tight The maintenance manual requirements were compared to 14 CFR Part 135.427 and no anomalies were found. According to maintenance records, the last major engine overhaul was performed by T.W. Smith Engine Co., Inc., on June 21, 1996. On April 16, 1997, the same repair station inspected the engine, following a propeller strike that occurred on March 5, 1997. According to the records, the engine was purchased by T.W. Smith in 1987. It remained in storage until June 1996, when the engine was purchased by Air Carriers, Inc., who had it overhauled by T.W. Smith. WREAKAGE AND IMPACT INFORMATION A diagram of the accident site prepared by the Fulton County Police Department is attached to the report. Scrapes were found in the pavement, approximately 150 to 200 yards northeast of the wreckage that correlated to the direction of flight. Concave scrapes, found in the same location, were approximately perpendicular to the direction of flight. These scrapes had a shape similar to that of propeller blades. Neither the airplane nor the Mazda broke apart after the collision, containing the wreckage in a small area under an overpass bridge. The engine was found attached to the firewall, and the propeller hub was still connected to the engine. The fuselage, empennage, and the wings were partially consumed by fire. There was continuity of the flight controls from the cockpit area to the control surfaces. The flap mechanism was found in the retracted position. All three landing gear were found in the retracted position. The airplane wreckage was moved to a salvage facility at Griffin, Georgia, where the engine was disassembled. The number5 connecting rod was found broken with connecting rod, bearing and crankcase material in the oil sump. The oil suction line was partially blocked with similar debris. Several connecting rods and bearings displayed heat damage including blue discoloration of the rods and extruded bearings. The crankshaft journals, except for the number5 rod journal exhibited heat distress and or gouging. MEDICAL AND PATHOLOGICAL INFORMATION Toxicology samples were not obtained by the pilot's medical treatment facilities. TESTS AND RESEARCH During a telephone interview with the Safety Board, a representative from T.W. Smith Engine Co., Inc. discussed the procedures followed when performing an engine overhaul. If the overhauled engine will be returned directly to the customer, the original connecting rods, if they pass inspection, are re-installed in the engine If the engine will be placed into storage, the connecting rods, as a set, go into storage along with other connecting rod sets. When an engine requires a set of connecting rods, one set is pulled from storage, and installed in the engine. When the accident engine was re-assembled after being in storage, it could not be determined if the original connecting rods were put back into the same engine. Since these connecting rods do not have specific part numbers, only casting numbers, it is difficult to track the progress of a particular connecting rod. In accordance with Textron Lycoming overhaul procedures, connecting rods may be reused until they fail to pass an inspection. The T.W. Smith represented stated that engine overhauls are done in accordance with the overhaul procedure for the reuse of connecting rods. A Mandatory Service Bulletin, Service Bulletin No. 439A, was sent out by Textron-Lycoming Engine Co. addressing the inspection of connecting rods for fretting and/or galling on August 18, 1993. In the service bulletin, it states that, "It has been found that the location of galling determines if the rod is or is not likely to fail. Galling marks in the bearing bore are critical except for the area directly under the I-beam of the rod. Do not scrap a rod because of galling that is confined to this area; but also do not reuse a rod having gall marks in the critical area." A metallurgical examination was performed in the Safety Board's Materials Laboratory of the number 5 connecting rod assembly, three unidentified pieces, and a clogged fuel injector. The material examination report has been included with this report. The report indicated that the connecting rod assembly displayed evidence of fatigue cracks that originated at or near areas of galling in the connecting rod bore. ADDITIONAL INFORMATION The operations manual for Air Carriers, Inc. was compared to 14 CFR135.23, and the airplane requirements were compared with 14 CFR135.25. No omissions were noted. The airplane wreckage, logs, and records were released to the insurance adjuster: Harry Brooks Carson-Brooks 2300 Peachford Road Suite 1200 Atlanta, Georgia 30338 The following individuals participated in the investigation: John B. Simmons Air Carriers, Inc. POB 400 Bessemer, Alabama 35022 Mike McClure Piper Aircraft Corporation 2301 Hunter Place Lane Arlington, Texas 76006 Ed G. Rogalski Lycoming POB 1493 11245 SE 47th Ave Belleview, Florida 34421
A loss of engine power due to the failure of the number five connecting rod assembly as a result of fatigue cracks that were initiated in areas of galling. A factor was the lack of suitable terrain for a forced landing.
Source: NTSB Aviation Accident Database
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