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Accidents · NTSB ERA18FA137 · Final report

Piper PA28R accident near Gainesville, Georgia, April 28, 2018

On April 28, 2018 at about 9:15 pm local time, a 1976 Piper PA28R, registered N4363F, was substantially damaged in an accident during enroute (cruise) near Gainesville, Georgia. It was an instructional flight under general aviation rules (Part 91). 1 person was killed and 2 people were seriously injured. The weather was visual conditions (good weather).

The NTSB's probable cause their words, unchanged

A partial loss of engine power due to inadequate thru-bolt and stud preload tension by undetermined maintenance personnel, which resulted in fretting between the engine crankcase halves, and the subsequent separation of the No. 2 cylinder due to the fatigue failure of the No. 2 cylinder stud/thru bolts.

Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.

What the record shows

Date
April 28, 2018 · about 9:15 pm local time
Place
Gainesville, Georgia · map
Type
Accident
Injuries
1 person was killed and 2 people were seriously injured.
Weather
visual conditions (good weather)
Aircraft
Piper PA28R 200, built 1976 · all PA28Rs on the register
Registration
N4363F · no longer on the register · serial 28R-7635406
Damage
Substantial damage
Flight
Instructional flight · general aviation rules (Part 91)

The NTSB's narrative final · quoted from the NTSB record

The commercial pilot receiving instruction and a flight instructor were conducting a local instructional flight when the engine lost partial power and oil obscured the front windscreen. The instructor took control of the airplane and maneuvered toward a highway on which to conduct a forced landing; the airplane struck power lines and a vehicle before veering off the road and down a steep embankment, where it came to rest inverted. Examination of the engine revealed that the No. 2 cylinder had separated from the cylinder mounting deck. The No. 2 cylinder rocker box cover and a pushrod tube were protruding from the left forward side of the cowling. The No. 2 cylinder connecting rod was protruding through the top of the cowling. The No. 2 cylinder base studs and thru bolts remained in the crankcase and were fractured at their threaded section. Metallurgical examination revealed that each of the fractured surfaces exhibited evidence of crack arrest marks consistent with fatigue cracking and microvoid coalescence features typical of overstress separation. The crankcase web mating surfaces at the Nos. 2, 3 and 4 bearing journals exhibited pitting consistent with fretting, which is typically a result of inadequate preload tension or loss of preload tension to the fasteners that secure the cylinder to the engine. The inadequate or loss of preload resulted in fatigue cracking of the No. 2 cylinder studs and thru-bolts, and the subsequent separation of the cylinder. According to maintenance records, the engine underwent a major overhaul about 4 years before the accident and had accrued 1,071.11 hours since the last overhaul. At the time of the overhaul, the crankcase was reassembled, and all four cylinders were installed. It could not be determined if the thru-bolts and studs were improperly tightened by maintenance personnel at the time of the overhaul or during an undocumented maintenance action that was performed after the overhaul. Toxicology testing of the flight instructor revealed an unquantifiable amount of doxylamine, a sedating antihistamine that was well below that considered to cause significant effects. Therefore, it is unlikely that the pilot's use of doxylamine contributed to his inability to successfully perform a forced landing on a highway.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

The factual record from the NTSB's investigation tables, in plain English

What happened, in order

  1. Aircraft maintenance event during prior to flight
  2. Loss of engine power (partial) during enroute (cruise) defining event
  3. Off-field or emergency landing during emergency descent
  4. Collision with terrain or object (not controlled flight into terrain) during emergency descent
  5. Collision with terrain or object (not controlled flight into terrain) during landing (flare/touchdown)

The NTSB's findings

  • cause Aircraft › Aircraft power plant › Engine (reciprocating) › Recip engine power section › Incorrect service/maintenance
  • cause Aircraft › Aircraft power plant › Engine (reciprocating) › Recip engine power section › Fatigue/wear/corrosion
  • cause Aircraft › Aircraft power plant › Engine (reciprocating) › Recip engine power section › Failure
  • cause Personnel issues › Task performance › Maintenance › (general) › Maintenance personnel

Flight instructor

  • Certificate: flight instructor, commercial pilot, private
  • Ratings: single-engine land; instructor: airplane single-engine; instructor: instrument airplane; instrument: airplane
  • Flight time: 671 hours in all
  • Last flight review: April 10, 2018
  • Medical certificate: Class 2 (without waivers/limitations)
  • Seat: rgt
  • Injury: fatal

Pilot

  • Certificate: commercial pilot, private
  • Ratings: multi-engine land; single-engine land; instrument: airplane
  • Flight time: 560 hours in all
  • Last flight review: May 6, 2015
  • Medical certificate: Class 3 (without waivers/limitations)
  • Seat: left
  • Injury: serious injuries

The aircraft

  • Airframe total time: 5,515.0 hours
  • Last inspection: annual inspection, February 6, 2018; 37 hours since
  • Seats: 4
  • Landing gear: retractable
  • Engine: Lycoming IO-360-C1C (piston); 1,071 hours total
  • Fire on the ground

The flight

  • Departed from: LZU Lawrenceville GA at 8:15 pm
  • Destination: LZU Lawrenceville GA
  • Flight plan: none
  • A second pilot was aboard

Weather at the time

  • Light: daylight
  • Wind: from 250° at 8 knots
  • Visibility: 10 statute miles
  • Sky: a few clouds at 8,000 ft
  • Temperature: 77°F (25°C), dew point 41°F (5°C)
  • Altimeter: 29.92 inHg
  • Observation at 8:56 pm from LZU, 16 miles away

Injuries

FatalSeriousMinorNone
Flight crew11
Passengers1

Documents from the investigation the NTSB's docket: the evidence folder behind the report

12 documents, released by the NTSB on November 13, 2019. View them here, or download them; the NTSB redacts some personal details before release, and this site shows the NTSB's own titles rather than its file names.

The same docket at the NTSB · documents without a copy here are fetched from the NTSB when you open them.

Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.