Tuesday, December 15, 2009
It’s critical to ensuring a safe flight
On May 30, 2008, a Piper PA28-235 crashed after takeoff from Highland County Airport in Hillsboro, Ohio. The pilot and passenger were killed. The plane was flying VFR to its home base in New Carlisle, Ohio, after receiving maintenance on its autopilot. According to an FAA inspector, after the maintenance was completed, the airplane initially departed but returned due to smoke in the cockpit. A technician checked the cockpit and autopilot but didn’t find any discrepancies.
On the second takeoff, a witness saw the plane lift off from runway 23 and climb to between 300 and 400 feet before gray smoke started coming out of its right front side. As the smoke blackened, the airplane “veered” to the left; it eventually descended and impacted a tree with its left wing.
In its report, the NTSB quoted the 1973 Piper PA28-235’s flight manual, which advises “the presence of fire is noted through smoke, smell, and heat in the cabin. It is essential that the source of fire be promptly identified through instrument readings, character of the smoke, or other indications, since the action to be taken differs somewhat in each case. The emergency procedures for an in-flight engine fire are: a. Fuel Selector—Off; b. Throttle—Closed; c. Mixture—Idle Cut-Off; d. Heater—Off (in all cases of fire); e. Defroster—Off (in all cases of fire); f. If terrain permits, land immediately.”
The Piper Cherokee’s service manual, dated January 31, 2008, has a 12-page checklist for 50- and 100-hour inspections. Within the list of items dealing with the engine, two items pertain to the exhaust system. One states, “Inspect exhaust stacks, connections and gaskets per Exhaust System Inspection. (See Special Instructions, Procedures.) Replace gaskets as required.” The second item states, “Inspect muffler, heat exchange and baffles per Exhaust System Inspection. (See Special Instructions, Procedures.)”
According to the FAA, the mechanic who had performed the accident airplane’s previous five inspections also had done 42 annual inspections on other aircraft in the same year. He worked out of his hangar and didn’t have any calibrated tools. The checklist he used was one page in length and contained 16 items. One item pertaining to the muffler only had the word “Muffler” with a checkmark next to it.
The muffler and right exhaust stack were examined by the NTSB’s Materials Laboratory in Washington, D.C. A hole was observed in the inwardly deformed lower portion of the muffler’s housing, adjacent to its left end. The left portion of the muffler had deposits and residual burnt insulating material consistent with a fire. The hole’s edges were ragged and displayed radially oriented cracks, predominately on the forward and right edges. Manipulation of the protruding portion of the edge revealed that they could be separated from the muffler by applying as few as three bending cycles. The forward and rear ragged edges of the hole couldn’t be mated, suggesting there was some material missing. A sample of the muffler skin’s inner surface at the rear of the hole displayed areas of an undulating surface consistent with corrosion deterioration. Other areas were covered with brown patches, which, when rubbed with the wooden end of a cotton-tipped applicator, fell off in flakes to reveal a similar undulating surface.
The right exhaust stack was extracted from the muffler to reveal that the middle pipe portion was mechanically damaged, visibly tapered and out-of-round. Examination of the middle pipe’s damaged end revealed several localized areas of inward deformation and a longitudinal cut with inward bends. The out-of-round shape of the exhaust stack’s middle pipe was mirrored in the shape of the muffler’s center pipe.
The NTSB determined that the probable cause of this accident was the pilot’s failure to maintain control of the airplane due to an in-flight fire resulting from a corrosion hole in the muffler that wasn’t identified by a mechanic.
Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other NTSB news. To subscribe, write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.
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