Hurricane - Salt Lake City

Shortly after takeoff, the pilot smelled smoke. As he began to turn the airplane back to the airport, the engine lost total power. He conducted a forced landing in a field just short of the airport, during which the airplane struck a metal fence and pipe. All occupants egressed, and the pilot then noticed that a fire had erupted under the airplane's engine cowling. Postaccident examination revealed that the airplane sustained fire damage to the roof and forward end of the baggage compartment along with the engine accessory area between the firewall and aft air baffles. Further examination revealed that one of the engine exhaust crossover pipe assemblies was misaligned at the slip joint. An engine manufacturer service bulletin (SB) called for inspections of the exhaust system slip and flange joints to identify misaligned exhaust components. The last maintenance event occurred about 7 1/2 flight hours before the accident, during which the SB was performed and resulted in the replacement of crossover pipes. The mechanic who had performed the most recent maintenance did not follow the correct procedures for reinstallation of the crossover pipe, and the inspector who reviewed his work did not examine the installation as it progressed but instead inspected the pipes after they were installed and essentially hidden from view by their protective heat shield. As a result of the misaligned engine exhaust crossover pipe, hot exhaust gases escaped into the engine compartment and started a fire, which compromised critical engine fuel and oil lines, and resulted in the loss of engine power.

Flight / Schedule

Hurricane - Salt Lake City

Registration

N413LL

MSN

46-36413

Year of Manufacture

2007

Date

October 21, 2018 at 03:00 PM

Type

CRASH

Flight Type

Private

Flight Phase

Takeoff (climb)

Crash Site

Airport (less than 10 km from airport)

Crash Location

Hurricane Utah

Region

North America • United States of America

Coordinates

37.1750°, -113.2899°

Crash Cause

Human factor

Narrative Report

On October 21, 2018 at 03:00 PM, Hurricane - Salt Lake City experienced a crash involving Piper PA-46 (Malibu/Meridian/Mirage/Matrix/M-Class), operated by Keystone Aviation, with the event recorded near Hurricane Utah.

The flight was categorized as private and the reported phase was takeoff (climb) at a airport (less than 10 km from airport) crash site.

5 people were known to be on board, 0 fatalities were recorded, 5 survivors were identified or estimated. This corresponds to an estimated fatality rate of 0.0%.

Crew on board: 1, crew fatalities: 0, passengers on board: 4, passenger fatalities: 0, other fatalities: 0.

The listed crash cause is human factor. Shortly after takeoff, the pilot smelled smoke. As he began to turn the airplane back to the airport, the engine lost total power. He conducted a forced landing in a field just short of the airport, during which the airplane struck a metal fence and pipe. All occupants egressed, and the pilot then noticed that a fire had erupted under the airplane's engine cowling. Postaccident examination revealed that the airplane sustained fire damage to the roof and forward end of the baggage compartment along with the engine accessory area between the firewall and aft air baffles. Further examination revealed that one of the engine exhaust crossover pipe assemblies was misaligned at the slip joint. An engine manufacturer service bulletin (SB) called for inspections of the exhaust system slip and flange joints to identify misaligned exhaust components. The last maintenance event occurred about 7 1/2 flight hours before the accident, during which the SB was performed and resulted in the replacement of crossover pipes. The mechanic who had performed the most recent maintenance did not follow the correct procedures for reinstallation of the crossover pipe, and the inspector who reviewed his work did not examine the installation as it progressed but instead inspected the pipes after they were installed and essentially hidden from view by their protective heat shield. As a result of the misaligned engine exhaust crossover pipe, hot exhaust gases escaped into the engine compartment and started a fire, which compromised critical engine fuel and oil lines, and resulted in the loss of engine power.

Aircraft reference details include registration N413LL, MSN 46-36413, year of manufacture 2007.

Geospatial coordinates for this crash are approximately 37.1750°, -113.2899°.

Fatalities

Total

0

Crew

0

Passengers

0

Other

0

Crash Summary

Shortly after takeoff, the pilot smelled smoke. As he began to turn the airplane back to the airport, the engine lost total power. He conducted a forced landing in a field just short of the airport, during which the airplane struck a metal fence and pipe. All occupants egressed, and the pilot then noticed that a fire had erupted under the airplane's engine cowling. Postaccident examination revealed that the airplane sustained fire damage to the roof and forward end of the baggage compartment along with the engine accessory area between the firewall and aft air baffles. Further examination revealed that one of the engine exhaust crossover pipe assemblies was misaligned at the slip joint. An engine manufacturer service bulletin (SB) called for inspections of the exhaust system slip and flange joints to identify misaligned exhaust components. The last maintenance event occurred about 7 1/2 flight hours before the accident, during which the SB was performed and resulted in the replacement of crossover pipes. The mechanic who had performed the most recent maintenance did not follow the correct procedures for reinstallation of the crossover pipe, and the inspector who reviewed his work did not examine the installation as it progressed but instead inspected the pipes after they were installed and essentially hidden from view by their protective heat shield. As a result of the misaligned engine exhaust crossover pipe, hot exhaust gases escaped into the engine compartment and started a fire, which compromised critical engine fuel and oil lines, and resulted in the loss of engine power.

Cause: Human factor

Occupants & Outcome

Crew On Board

1

Passengers On Board

4

Estimated Survivors

5

Fatality Rate

0.0%

Known people on board: 5

Operational Details

Schedule / Flight

Hurricane - Salt Lake City

Flight Type

Private

Flight Phase

Takeoff (climb)

Crash Site

Airport (less than 10 km from airport)

Region / Country

North America • United States of America

Aircraft Details

Registration

N413LL

MSN

46-36413

Year of Manufacture

2007