Ontario International Airport
Aircraft Accident/Incident Report

Ontario, California 91761
Thursday, June 10, 2010 16:27 PDT

NTSB Narrative Summary Released at Completion of Accident

The pilot was conducting a cross-country flight with a certified flight instructor (CFI). During the climb-to-cruise phase of the flight, as the airplane was ascending through 16,000 feet mean sea level (msl), the pilot noticed a reduction in manifold pressure. He advanced the throttle and observed an increase of one or two inches of manifold pressure. Shortly thereafter, the pilot heard a loud bang originate from the engine followed by an immediate loss of engine power. The pilot and CFI attempted to troubleshoot the engine anomalies and noted that it seemed to respond with the low boost "on", however it began to run rough whenever the throttle was advanced more than half way. They diverted to a nearby airport and conducted an emergency descent. As the airplane approached the airport, the pilot descended through an overcast cloud layer and attempted to enter the airport traffic pattern. While on final approach to the airport, the pilot thought the airplane was high and extended the landing gear and applied flaps. Shortly thereafter, the airspeed and altitude decreased drastically and the pilot realized he was too low. The pilot applied throttle and noticed no change in engine performance. The airplane subsequently struck a fence and landed hard in an open field just short of the airport, which resulted in structural damage to the fuselage and wings. A postaccident examination of the engine revealed that the induction elbow for cylinders 1-3-5 (right side) was displaced from the throttle and metering assembly where the elbow couples with the throttle and metering assembly by an induction hose and clamp. The clamp was secure to the induction hose, however, the portion of the clamp that should have been installed beyond the retention bead on the throttle and control assembly was observed on the inboard side of the bead on the induction elbow. Review of the aircraft maintenance logbooks revealed that cylinders 4 and 5 were recently replaced prior to the accident flight due to low compression. The replacement of these cylinders required removal of the induction system to allow for cylinder removal and installation. In addition, a manufacturer service bulletin stated that during the reinstallation of the induction system, one must slide the induction hose and clamp(s) onto one of the tubes to be joined and that the connection joint and both tube beads are to be positioned in the center of the induction hose. The clamps should be installed in a position centered between the tubing bead and end of the induction hose.

NTSB Probable Cause Narrative

A loss of engine power due to the in-flight separation of the 1-3-5 cylinder induction tube elbow, which was caused by the improper installation of the induction tube elbow by maintenance personnel.

Event Information

Type of Event Accident
Event Date 6/10/2010
Event Day of the Week Thursday
Time of Event 1627
Event Time Zone Pacific Daylight Time
Event City Ontario
Event State CALIFORNIA
Event Country --
Zipcode of the event site 91761
Event Date Year 2010
Event Date Month 6
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 340321N
Event Location Longitude 1173604W
Event Location Airport Ontario International Airport
Event Location Nearest Airport ID ONT
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 1
Degrees magnetic from airport --
Airport Elevation 944
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1651 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 260
Weather Observation Facility ID ONT
Elevation of weather observation facility 944
Distance of event from weather observation facility (units?) 1
Time Zone of the weather observation PDT
Lighting Conditions Day
Lowest Ceiling Height 3700
Lowest Non-Ceiling Height 3700
Sky/Lowest/Cloud Conditions Thin Broken
Sky Condition for Lowest Ceiling Broken
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) 13
Wind Direction (degrees magnetic) 260
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 8
Wind Velocity Indicator --
Wind Gust Indicator Gusting
Wind Gust (knots) 16
Altimeter Setting at event time (in. Hg) 29.85
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Serious
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor 1
Injury Total None --
Injury Total Serious 1
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 27994
NTSB Notification Source FAA Operations Center
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record May 11 2011 12:22PM
User who most recently changed record rows
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N121HJ
NTSB Number WPR10LA284
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? --
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name PIPER
Aircraft Model PA-46-310P
Aircraft Series Identifier --
Aircraft Serial Number 468508105
Certified Max Gross Weight 4100
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 6
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Sep 23 2009 12:00AM
Airframe hours since last inspection --
Airframe Hours 4803
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type Unknown
Aircraft Owner Name THEODORE JOSEPH POELKING
Aircraft Owner Street Address --
Aircraft Owner City Waynesville
Aircraft Owner State OH
Aircraft Owner Country USA
Aircraft Owner Zipcode 45068
Operator is an individual? No
Operator Name THEODORE JOSEPH POELKING
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City Waynesville
Operator State OH
Operator Country USA
Operator Zip code 45068
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? No
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) Instructional
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code SMO
Departure City Santa Monica
Departure State CA
Departure Country USA
Departure Time 1550
Departure Time Zone PDT
Destination Same as Local Flt --
Destination Airport Code HII
Destination City Lake Havasu
Destination State AZ
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 27 2011 2:14PM
User who most recently changed record stam
Since inspection or accident Last Inspection
Event Location Runway Number and Location N/A
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --