What happened
On December 5, 2016, a Piper PA28-161, registration HK4664G, was conducting a solo flight training mission near Ernesto Cortissoz International Airport in Soledad, Colombia. While climbing through 2,300 feet, the student pilot noticed a drop in engine RPM. The pilot immediately leveled the aircraft and notified air traffic control of potential magneto issues, requesting to return to the airport.
During the approach, the engine failed completely. After two unsuccessful attempts to restart the engine, the pilot determined the aircraft could not reach the runway and executed an emergency landing in a mangrove area near Isla Cabica. The aircraft landed in the water and began to submerge. The pilot was able to evacuate the aircraft on his own and was later rescued by local fishermen.
The investigation
The GRIAA investigation revealed that the aircraft had a history of engine-related issues. Maintenance records showed six separate reports of engine malfunctions between June and December 201 and included events such as engine failure after takeoff, fuel leaks, and engine vibrations. Although these issues were documented as corrected, the investigation found that the root cause was never definitively addressed.
Furthermore, the investigation noted a loss of the chain of custody for the engine. The operator performed maintenance and inspections on the engine and its components before investigators could examine them, making it impossible to conclusively determine the exact origin of the failure.
Findings
- The primary cause of the incident was an engine shutdown of undetermined origin, which occurred following a series of previous engine failures that were not adequately tracked to identify and correct the underlying cause.
- The operator's maintenance quality and safety systems were weak, failing to take decisive action to address the repetitive engine malfunctions.
- The operator's Safety Management System (SMS) failed to detect or implement efficient procedures for communicating repetitive engine issues between the maintenance department and safety management.
- The student pilot was fully qualified, with a valid medical certificate and up-to-date training.