30 Aug 2019: Piper PA-18

30 Aug 2019: Piper PA-18 (N1124) — Unknown operator

No fatalities • Fairbanks, AK, United States

Probable cause

The inappropriate application of paint underneath the engine cylinder hold-down nuts, which resulted in inadequate torque and the subsequent in-flight separation of the No. 3 cylinder, and resulted in a total loss of engine power.

— NTSB Determination

Accident narrative

On August 30, 2019, at about 1310 Alaska daylight time, a float-equipped Piper PA-18 airplane, N1124, sustained substantial damage during a forced landing following a total loss of engine power while in cruise flight near Fairbanks, Alaska. The commercial pilot was not injured. The airplane was privately owned and operated by the pilot, under the provisions of Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed and a flight plan had been filed. The flight departed Chena Marina Airport (AK28), Fairbanks, Alaska. According to the pilot, she had been airborne for about 2 1/2 hrs when the engine began to sound "funny", and she decided to return to AK28. About 16 minutes later and 13 miles west of AK28 the engine lost all power, and she conducted an emergency landing to a heavily forested area. The airplane sustained substantial damage to the wings. An initial examination of the engine revealed that the No. 3 cylinder had separated from the engine's case. The airplane was equipped with a narrow deck Lycoming O-320-A1H engine. A detailed engine examination revealed that the bottom two cylinder hold down studs for the No. 3 cylinder were intact, and the stud's threads were in relatively good condition. The remaining cylinder hold down studs were fractured, with fretting present on the engine's case. In addition, black paint was chipped and broken around the cylinder's hold down nuts, and paint was present inside the cylinder hold down stud holes located on the cylinder's flange. Paint was not present on the backside of the cylinder's flange.

Figure 1 – Remnants of black paint visible in one of the bottom of the No. 3 cylinder stud holes.

Figure 2 - Black paint visible in a cylinder stud hole on the No. 3 cylinder.

Figure 3 - No. 3 cylinder bottom two cylinder studs with fretting visible on engine's case.

Figure 4 - Back side of No. 3 cylinder's flange.

Maintenance records revealed that the airplane engine's cylinders had been replaced on July 24, 2003, about 815.7 hours before the accident with overhauled cylinder assemblies. The most recent annual inspection of the airframe and engine was completed on September 11, 2018. Lycoming's Overhaul Manual – Lycoming Direct Drive Aircraft Engines, Section 3, General Overhaul Procedures stated in part: Note All machined bosses should be masked before painting. Do not paint areas under hold down nuts where torque is required. The closest weather reporting facility is Fairbanks International Airport, (PAFA), Fairbanks, Alaska. At 1353, a METAR from PAFA was reporting in part: wind, 020 at 4 knots; visibility, 10 statute miles; sky condition, few clouds 6,000 ft, few clouds 10,000 ft; temperature, 63° F; dew point 43° F; and an altimeter setting of 30.04 inches of mercury. In the recommendation section of the National Transportation Safety Board Accident/Incident Reporting Form 6120.1, the pilot stated that when she made the decision to return to AK28 no suitable landing areas were close by; however, if she would have proceeded directly to a suitable lake for landing rather than attempting to return to her departure airport, the accident may have been avoided.

Contributing factors

  • Maintenance personnel
  • Incorrect service/maintenance

Conditions

Weather
VMC, wind 020/04kt, vis 10sm

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