History of Flight
On November 22, 2009, at about 1330 eastern standard time, a Piper PA-28R-200, N345AT, was substantially damaged when it struck trees and terrain during a forced landing near Wappinger, New York. The commercial pilot and pilot-rated passenger were fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight conducted under Part 91. The aircraft departed Orange County Airport (MGJ) in Montgomery, New York, at about 1313, destined for Danbury Municipal Airport (DXR) in Connecticut.
According to FAA air traffic control information, the pilot contacted ATC shortly after departure to request flight following. At about 1325, the pilot reported an oil problem and stated they were diverting to Dutchess County Airport (POU) in Poughkeepsie, New York. Radar data showed the aircraft at 3,900 feet msl, about 6.8 nautical miles south of POU. At 1326, the pilot declared a loss of engine power, with the aircraft at 3,000 feet msl and 5.2 nautical miles south of the airport. The controller and pilot discussed alternative landing sites, including a nearby highway. At 1328, the pilot indicated he could not reach the highway and would attempt to land to his right. Radio contact was lost, and the last radar target was recorded 2.5 nautical miles south of POU at 200 feet msl.
Personnel Information
FAA records show the pilot held a commercial pilot certificate with ratings for airplane single-engine land and sea, and instrument airplane. On his most recent second-class medical certificate, issued February 4, 2009, he reported 1,100 total hours of flight experience.
Aircraft Information
The four-seat, low-wing, retractable-gear aircraft, serial number 28R-7435303, was manufactured in 1974. It was powered by a Lycoming IO-360-C1C, 200-horsepower engine. Maintenance records from the co-owner indicated the engine had accumulated about 1,714 hours since its last overhaul on May 8, 1991, at an aircraft total time of 2,959 hours. After a sudden stoppage in May 1993, about 339 hours post-overhaul, the engine was inspected and repaired, including installation of eight "SL74309 M03" connecting rod bearings. The engine returned to service in July 1993 and subsequently logged 1,363 operational hours through August 2009. During this period, 19 oil changes were recorded, with 6 specifically noting inspection of the oil filter or suction screen. An entry from November 2004 noted non-ferrous material in the filter, recommending a recheck in 25 hours. The next entry in February 2005 reported no contamination. This was the last oil filter inspection noted. The most recent annual inspection was completed on August 1, 2009, at a tachometer time of 1,362 hours and aircraft total time of 4,662 hours. The final engine log entry, dated September 9, 2009, about 4.8 flight hours before the accident, documented replacement of the engine-driven fuel pump due to an oil leak, with no leaks found after run-up.
Meteorological Information
The weather reported at POU at 1353 included clear skies, 10 statute miles visibility, winds from 010 degrees at 9 knots, temperature 11°C, dewpoint 3°C, and an altimeter setting of 30.32 inches of mercury.
Wreckage and Impact Information
The accident site was in a densely wooded private lot at an elevation of 239 feet, near the final radar target. Initial impact was with a 60-foot-tall tree. The wreckage path oriented about 195 degrees magnetic from the tree, with broken branches and small debris. The main wreckage, comprising the fuselage, both wings, and tail section, came to rest inverted about 190 feet from the initial impact, oriented approximately 230 degrees magnetic. The outboard 4 feet of the left wing was separated. Control continuity was established. All three landing gear were down and locked, though the gear selector was in the up position. Flaps were set to 10 degrees, and the stabilator trim tab was deflected nose-up. Both fuel tanks were ruptured, with a strong fuel odor. No oil staining or spray patterns were noted on the fuselage, and no evidence of pre- or post-impact fire was found.
The propeller remained attached to the crankshaft; one blade was bent aft about 16 inches from the tip, while the other appeared straight. The engine showed impact damage; drivetrain continuity was confirmed. During cursory examination, oil drained from the engine as it was separated. The oil filler cap was installed, but the filler neck was separated. The top spark plugs were removed: three appeared dark gray with no abnormal wear, and one was oil-soaked. The oil suction screen and filter element were contaminated with ferrous and non-ferrous metal. The engine was retained for detailed inspection.
At a recovery facility, the engine was disassembled. An undetermined quantity of oil drained from the crankcase. No damage was noted to rear accessory gears, valves, or rockers. The oil pump had light radial scoring on the cavity walls, and impeller gears were intact. Cylinders 1 and 2 were removed with no piston damage; their connecting rods moved freely on the journals, and bearings showed pitting and embedded material. Cylinders 3 and 4 could not be separated due to damage; the number 4 connecting rod was free, but the number 3 connecting rod was separated from the crankshaft. Portions of the number 3 connecting rod, cap, and bolts were found in the oil sump, along with other debris. A complete bearing for the number 3 rod was missing. The number 3 journal had a circumferential groove consistent with a bolt shank and exhibited thermal bluing. Components were sent to the NTSB Materials Laboratory.
Medical and Pathological Information
An autopsy of the pilot was performed by the Dutchess County Medical Examiner. Toxicological testing by the FAA showed no traces of carbon monoxide, cyanide, or ethanol.
Tests and Research
The NTSB Materials Laboratory conducted a metallurgical examination. Journals 1, 2, and 4 were smooth; journal 3 showed rotational scoring, heat tinting, and metal transfer. A semicircular wear groove was present on the number 3 journal. The connecting rod saddle bore had heat tinting and sliding contact marks. The number 3 connecting rod was fractured in the saddle at two places, with fatigue features emanating from origin areas. Post-fracture contact damage was observed. The number 4 connecting rod was cut for bearing examination; bearings showed dark gray color, pits, and rubbed areas. The installed bearings were marked SL74309 M03, which are undersized by 0.003 inches compared to standard. Measurements of the number 1 and 2 connecting rod journals (2.2469 and 2.2468 inches) were within 0.003 inch less than as-manufactured specifications. Metal pieces consistent with bearing material recovered from the crankcase showed various tints and sliding contact marks.
Additional Information
The J.P. Instruments EDM-700 engine monitoring unit was recovered and its non-volatile memory downloaded. The unit recorded parameters every six seconds, with 13,293 total records spanning multiple flights. The accident flight comprised the final 256 records (0:26:36). Data showed that about 9 minutes after recording began, exhaust gas temperatures of all four cylinders rose from about 1,000°F to 1,330°F over 30 seconds, consistent with takeoff. Oil temperature climbed gradually, stabilizing around 200°F, then began increasing about 5 minutes later, peaking at 259°F at 0:22:36. Battery voltage dropped from 14.3 to 12.4 volts around that time and remained below 12 volts; all temperature parameters then decreased.
An Australian Airworthiness Bulletin (AWB 85-1, issued April 4, 2006) listed factors that may lead to bearing failure in Lycoming engines, including inadequate oil supply, incorrect bearing clearances, high oil temperature, propeller strike, and failure to pre-oil after engine change or inactivity. It recommended oil and filter changes per Lycoming service bulletins, inspecting the oil filter for bearing condition, pre-oiling per service instructions, following cold weather start procedures, and reporting engine malfunctions or exceedances.
The Piper Cherokee Service Manual specified replacing full-flow oil filters every 50 hours of engine operation and examining the filter element for evidence of internal engine damage, such as bearing particles. Lycoming Service Bulletin Number 480E provided similar recommendations for oil and filter change intervals and filter content inspection.