Seminole Lake Airport
Aircraft Accident/Incident Report

Groveland, Florida 34736
Friday, April 15, 2005 14:40 EDT

NTSB Narrative Summary Released at Completion of Accident

The pilot/mechanic arrived at the Seminole Lake Gliderport to repair the engine following an uneventful precautionary landing the day before due to a bent exhaust pushrod of the No. 2 cylinder. He replaced the damaged No. 2 cylinder exhaust pushrod, pushrod housing, pushrod seals and lock tab. He reported visually inspecting the valve springs which did not appear to be damaged, but did not inspect the valve, nor did he remove the cylinder. Following the repairs, the engine was started and a full static run-up was performed with no discrepancies noted. The flight departed for Kissimmee Gateway Airport and shortly after takeoff, the engine started running rough though it was still producing power. He elected to return to the Seminole Lake Gliderport and after recognizing he was going to overshoot the runway with the engine not producing full power, elected to perform a 360-degree turn back onto final approach. During the turn, the aircraft impacted trees and came to rest in a swamp south of the south edge of runway 18. A pilot-rated witness observed the airplane on final approach and noted that as it descended to treetop level, or the height of the buildings, the airplane began to abruptly pitch up and down and was abruptly yawing. It appeared to the pilot-rated witness that some of the motions of the airplane did not coincide with the wind conditions that he observed. Postaccident examination of the engine by an FAA inspector revealed the replaced pushrod was damaged on both ends, with no obvious indication of a stuck valve. Additionally, the rotator type exhaust valve stem cap was missing from under the exhaust rocker arm of the No.2 cylinder. The exhaust valve and guide were within new limits in compliance with the Lycoming overhaul manual. There was no evidence of carbon inside the guide; however, there was swirl marks from reaming of the guide. Review of Lycoming Service Bulletin (SB) No. 388C revealed inspection procedures to be carried out at 400 hours or earlier, when valve sticking is suspected. The SB indicates that failure to comply with this provision could result in sticking valves, or broken exhaust valves which could result in engine failure. A section of the SB outlines the inspection procedure that uses a "GO/NO-GO" gage, and recommends moving the exhaust valve completely out of the guide to avoid interference when using the GO/NO-GO gage to check the guide for wear or carbon build up. The mechanic did not report using the GO/NO-GO gage. Additionally, the mechanic did not report using a local manufactured tool.

NTSB Probable Cause Narrative

The pilot's poorly planned approach during a precautionary landing following partial loss of engine power resulting in a go-around and subsequent in-flight collision with trees. A contributing factor in the accident was the inadequate maintenance by the mechanic/pilot for his failure to comply with Lycoming SB 388C, following a stuck exhaust valve.

Event Information

Type of Event Accident
Event Date 4/15/2005
Event Day of the Week Friday
Time of Event 1440
Event Time Zone Eastern Daylight Time
Event City Groveland
Event State FLORIDA
Event Country --
Zipcode of the event site 34736
Event Date Year 2005
Event Date Month 4
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 282414N
Event Location Longitude 0815022W
Event Location Airport SEMINOLE LAKE
Event Location Nearest Airport ID 6FL0
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation 120
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1453 Eastern Daylight Time
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID KLEE
Elevation of weather observation facility 77
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation EDT
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 22
Dew Point at event time (in degress fahrenheit) 3
Wind Direction (degrees magnetic) 60
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 12
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.06
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None 1
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 18510
NTSB Notification Source FAA FSDO
NTSB Notification Date Apr 15 2005 12:00AM
NTSB Notification Time 1503
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Oct 27 2005 6:51AM
User who most recently changed record NTSB\JOHB
Basic weather conditions Visual Meteorological Cond
FAA District Office Orlando, Florida

Aircraft Involved

Aircraft #1

Aircraft Registration Number N270FT
NTSB Number MIA05LA093
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? No
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Piper
Aircraft Model PA-28-161
Aircraft Series Identifier --
Aircraft Serial Number 2841212
Certified Max Gross Weight 1470
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 4
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection 100 Hour
Date of Last Inspection Mar 1 2005 12:00AM
Airframe hours since last inspection 90.9
Airframe Hours 8693
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name M & A Aviation, Inc.
Aircraft Owner Street Address 1001 N. Central Avenue
Aircraft Owner City KISSIMMEE
Aircraft Owner State FL
Aircraft Owner Country USA
Aircraft Owner Zipcode 34741
Operator is an individual? No
Operator Name Orlando Flight Training, Inc.
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 606 N. Dyer Boulevard
Operator City Orlando
Operator State FL
Operator Country USA
Operator Zip code 34741
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Ferry
Second Pilot on Board No
Departure Point Same as Event Yes
Departure Airport Code 6FL0
Departure City Groveland
Departure State FL
Departure Country USA
Departure Time 1433
Departure Time Zone EDT
Destination Same as Local Flt --
Destination Airport Code KISM
Destination City Kissimmee
Destination State FL
Destination Country USA
Specific Phase of Flight Maneuvering - turn to landing area (emergency)
Report sent to ICAO? No
Evacuation occurred Yes
Date of most recent change to record Jul 29 2005 1:24PM
User who most recently changed record KENJ
Since inspection or accident Time of Accident
Event Location Runway Number and Location 36
Runway Length 3000
Runway Width 200
Sight Seeing flight No
Air Medical Flight No
Medical Flight --