Concord, CA, USA
N2920C
Piper PA-28RT-201T
Following a loss of engine power in the takeoff initial climb, the airplane collided with vehicles during a forced landing on a freeway. During a cross-country flight the engine began to run rough and the pilot diverted to Concord. He phoned the FBO he rented the airplane from and advised them of the problem. The company contacted another maintenance facility at Concord who found a broken exhaust valve in the number 2 cylinder. The Concord maintenance facility estimated the repair job at 20 labor hours and the rental company declined to use them. The company dispatched a mechanic to Concord to make the repairs. The company mechanic replaced the number 2 cylinder and piston; however, he replaced the correct low compression piston with an incorrect high compression piston. He performed the work in just 3 hours. He failed to conduct a complete inspection of the engine for the missing pieces of the exhaust valve. After the mechanic verbally told the pilot the airplane was "good to go," the pilot fueled the airplane to capacity and completed the engine run up with no noted abnormalities. He departed using runway 19L, the shortest runway at CCR. When the airplane was about 150 to 200 feet above ground level, the pilot noted a loss of engine power. He decided he could not return to the airport and elected to land on the I-680 freeway. During the landing, the airplane collided with vehicles and came to rest in the center divider of the freeway. The airplane was largely consumed by the post impact fire. During the post accident engine examination, various determinations were made, including the following: Cylinders 2, 4, and 6 were mechanically damaged by a foreign object, most likely the number 2 exhaust valve head; the number 4 cylinder contained a foreign object that appeared to be a portion of the number 2 valve head; the spark plugs in cylinders 2, 4, and 6 were mechanically damaged with the electrode gaps closed or nearly so; cylinders number 1, 2, 4, 5, and 6 contained improper pistons that were certified to be installed into IO-360 series engines not into the accident engine a TSIO-360-FB; and the turbocharger turbine wheel exhibited foreign object damage. The number 2 main bearing was rotated 90 degrees. The bearing rotation and fretting damage to the number 2 and 3 upper main bearing support and the numbers 6 through 11 backbone bolt locations indicate that the through bolts were inadequately torqued during the installation of the number 2 cylinder.
HISTORY OF FLIGHT On April 13, 2004, about 1650 Pacific daylight time, a Piper PA-28RT-201T, N2920C, impacted vehicles on a freeway during a forced landing following a loss of engine power after takeoff from Buchanan Field Airport (CCR), Concord, California. The pilot rented the airplane from Kempton Air Services (KAS) and was operating the airplane under the provisions of 14 CFR Part 91. The private pilot and one passenger were not injured. One passenger riding in an automobile received serious injuries. The post impact fire destroyed the airplane. The personal cross-country flight departed CCR about 1650, en route to Walker Field Airport (GJT), Grand Junction, Colorado. Visual meteorological conditions prevailed, and no flight plan had been filed. The wreckage was at 37 degrees 58.30 minutes north latitude by 122 degrees 03.45 minutes west longitude. Federal Aviation Administration (FAA) inspectors interviewed the pilot at the Oakland Flight Standards District Office (FSDO). The pilot stated he had rented the airplane from KAS in Grand Junction. The pilot had flown the airplane to Gnoss Field Airport (DVO), Novato, California. During the flight, the pilot indicated he might have had a rough running engine, but he thought it was because of air turbulence. The pilot left the airplane parked at DVO for about a week. On April 12, 2004, the pilot and his son departed DVO for a return flight to GJT. After takeoff, the pilot noticed the engine running rough and decided to divert to Rio Vista Municipal Airport (088) and have a mechanic look at the engine. After landing at 088, the pilot discovered that there were no services available. The pilot contacted KAS and explained the problem he was having with the airplane. KAS suggested the pilot fly the airplane to CCR where services were available. The pilot made an uneventful flight to CCR. The pilot contacted Sterling Aviation, a fixed base operator at CCR. After examining the airplane, Sterling determined the number 2 cylinder had a broken exhaust valve. The director of maintenance for Sterling advised KAS it would take approximately 20 man hours to accomplish the repairs, which KAS declined. KAS decided to have a company mechanic flown to CCR to accomplish the repairs. On April 13, 2004, about 1300, the mechanic for KAS arrived at CCR to repair the airplane. Witnesses stated the mechanic worked on the airplane until about 1530-1600. The mechanic did not borrow any materials from Sterling to accomplish the repairs. Sterling reported that it received a request to refuel the airplane around 1600. The airplane taxied away from the Sterling facility about 1645. FAA inspectors subsequently interviewed the A&P mechanic who repaired the accident airplane. He stated he removed the number 2 cylinder and replaced it with a used cylinder, which he brought with him from KAS. After completing the cylinder change, the mechanic told the pilot the airplane was "good to go." The pilot stated he had the airplane fueled to capacity. After completing the engine run up with no abnormalities noted, the pilot departed using runway 19L. The pilot said that at about 150 to 200 feet above ground level, the airplane experienced a loss of engine power. He did not think he could return to the airport. He elected to land the airplane on the southbound side of the I-680 freeway. During the landing rollout, the left wing struck one vehicle, which breeched the left fuel tank. The right wing of the airplane struck a second vehicle, which spun the airplane around, and the propeller struck a passenger in the second vehicle. The airplane came to rest in the center divider of the freeway. The pilot and passenger exited the aircraft using the right side door exit. The post impact fire consumed a majority of the airplane. PERSONNEL INFORMATION A review of FAA airman records revealed that the pilot held a private pilot certificate with ratings for airplane single engine land and instrument airplane. The pilot held a third-class medical certificate, which was issued on April 2, 2001, with the limitation that the pilot must possess corrective glasses for near vision. The pilot reported an estimated total flight time of 280 hours. He logged 15 hours in the last 90 days. He had an estimated 40 hours in this make and model or aircraft. He completed a biennial flight review in November 2003. The mechanic who performed the maintenance on the airplane prior to the accident flight had an airframe and powerplant mechanics certificate, which was issued on June 17,1968. AIRCRAFT INFORMATION The airplane was a Piper PA-28RT-201T, serial number 28R-7931256. A review of the airplane's logbooks revealed a total airframe time of 6,416.5 hours at the last 100-hour inspection. The logbooks had an entry for an annual inspection dated August 12, 2003. The engine was a Teledyne Continental Motors TSIO-360-FB engine, serial number 310362. Total time since overhaul on the engine at the last 100-hour annual inspection was 2,300 hours. The manufacturer's recommended time between overhauls is 1,800 hours. Fueling records at CCR established that the airplane was last fueled on April 13, 2004, with the addition of 34.4 gallons of 100LL octane aviation fuel. Except for the previously noted problem with the number 2 cylinder, examination of the maintenance and flight department records revealed no other recorded unresolved maintenance discrepancies against the airplane prior to departure. METEOROLOGICAL INFORMATION The closest official weather observation station was Concord (CCR), which was located at the accident site. An aviation routine weather report (METAR) for CCR was issued at 1653. It stated: winds from 210 degrees at 11 knots; visibility 10 miles; skies were broken with clouds at 3,600 feet and 4,700 feet; temperature 17 degrees Celsius; dew point 9 degrees Celsius; and altimeter 30.10 inHg. COMMUNICATIONS The airplane was in contact with CCR airport traffic control tower (ATCT) on frequency 119.7. AIRPORT INFORMATION The Airport/Facility Directory, Southwest U. S., indicated that CCR has two sets of runways. They are 1L/19R, 1R/19L, 14L/32R, and 14R/32L. The longest runway, 1L/19R, was 5,001 feet long and 150 feet wide. The accident pilot utilized runway 1R/19L, which was 2,770 feet long and 75 feet wide and had an asphalt surface. WRECKAGE AND IMPACT INFORMATION The crash site was located approximately 1 1/2 miles south of the departure airport, in the southbound lanes of I-680. I-680 is an eight-lane highway with four lanes in each direction and a 3-foot high dividing wall between the north and southbound traffic. The on scene examination of the accident site by the FAA coordinator revealed that the wreckage distribution path of 164 feet was along a measured magnetic heading of 330 degrees. The main wreckage came to rest on a concrete retaining wall on the I-680 southbound lane. The beginning of the wreckage path began in the number 3 lane. A main impact ground scar was against the retaining wall. The cockpit and cabin areas were consumed by fire. The wings, vertical stabilizer, horizontal stabilator, and rudder were attached. The engine was still attached to the firewall. The nose landing gear was in place, and its position was extended. The post impact fire destroyed all cockpit instruments. The left wing was protruding over the retaining wall and attached to the fuselage. It was oriented upright and 30 degrees toward the energy path in a southerly direction. The California Highway Patrol moved the wing prior to the FAA inspector arriving on scene. The flap and aileron remained attached to the wing. The leading edge of the wing exhibited crushing, bending, twisting, and fire damage along its entire span. The fuel tank was breached with thermal damage. The position of the flap prior to impact could not be determined due to impact damage. The main landing gear was attached to the wings and collapsed due to the post impact fire. The right wing was attached to the fuselage. The wing was flat and collapsed due to the post impact fire. The leading edge was fragmented forward of the main spar, with the main spar exhibiting some impact deformation. Fire damage was noted on the inboard section of the wing, which exhibited sooting. The horizontal stabilator was attached to the vertical stabilizer and burned off of the fuselage in one piece. The stabilator was undamaged. The stabilator control cables were both intact from the "T" bar in the cockpit to the stabilator sector in the aft fuselage. The stabilator push-pull tube, which ran from the sector to the stabilator control horn, was burned. There was no fire damage to the vertical stabilizer, horizontal stabilator, or to the rudder. The ELT (emergency locator transmitter) could not be found on site. The propeller was attached to the crankshaft propeller attachment flange. The spinner was partially melted but still attached. All three blades were tight in the hub and bent opposite the direction of rotation. TESTS AND RESEARCH The FAA, Piper, and Teledyne Continental Motors (TCM) were parties to the investigation. Investigators examined the wreckage at Plain Parts, Sacramento, California, on April 14, 2004. Investigators removed the spark plugs from the engine. The number 2, 4, and 6 top and bottom plugs were mechanically damaged in that the electrode gaps were closed or partially closed. The factory representative stated that all of the spark plugs, with the exception of the top number 2 plug, were worn beyond normal service limits per the Champion spark plug chart AV-27. When the investigators found that the engine cylinders were mechanically damaged, the engine exam was discontinued. The engine was shipped to the Teledyne Continental Motors factory in Mobile, Alabama, for further examination. The FAA coordinator recovered the number 2 cylinder and piston that had been replaced by the mechanic prior to the accident flight. The number 2 cylinder and piston were also shipped to TCM for further examination. On November 16, 2004, at the Teledyne Continental Motors factory, the parties to the investigation conducted an examination of the accident engine and its components. The number 2 cylinder and piston that had been removed from the engine before the accident were examined. The piston (P/N 648048) was a 7.5:1 compression ratio piston, which was the correct piston for the (TSIO-360-FB) accident engine. The top of the piston had foreign object damaged. The exhaust valve was missing 2/3 of the head. The engine examination revealed the following: The engine was fire damaged, mainly at the rear of the engine. The cylinder's internal surfaces were inspected prior the removal from the engine using a borescope. Cylinders 2, 4, and 6 were mechanically damaged by what the TCM representative reported to be a foreign object. The number 4 cylinder combustion chamber contained a foreign object that appeared to be a portion of a valve head. The number 2, 4, and 6 top and bottom spark plugs were mechanically damaged. The pistons that were installed in cylinders 1, 2, 4, 5, and 6 were 8.5:1 compression ratio pistons, which are certified for use in the IO-360 series engine, but not the accident engine (TSIO-360-FB). The piston installed into cylinder number 3 was a 7.5:1 compression ratio piston, which was the correct piston for the (TSIO-360-FB) accident engine. The number two main bearing support was damaged from bearing rotation, the lock-slots were elongated from bearing movement, and severe fretting was present at the number 2 and 3 upper main bearing support and the number 6 through 11 backbone bolt locations. The number two crankshaft main bearings were found rotated 90 degrees upon engine disassembly. The turbocharger turbine wheel exhibited foreign object damage. ADDITIONAL INFORMATION The IIC released the wreckage to the owner's representative on January 12, 2005.
a loss of engine power due to improper maintenance repair procedures and use of improper parts.
Source: NTSB Aviation Accident Database
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