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ERA22LA169

2022-03-25 · Smithfield, North Carolina, United States · Serious · 1 aircraft · Status: Completed

Airport JNX

Current FAA registration · N471BL

Make / Model
DIAMOND AIRCRAFT DA 40 NG
Year of manufacture
2020 · 2 years old at event
Engine
AUSTRO E4-A (168 hp)
Seats / Engines
5 seats · 1 engine
Last airworthiness date
20201105
ADS-B equipped
Yes — Mode-S A5C4F5

Source: FAA Aircraft Registry (releasable master file).

Aircraft involved

Probable cause & findings

Maintenance personnel’s failure to set the correct engine timing after the replacement of a cylinder head and exhaust camshaft before the accident flight, which resulted in a total loss of engine power.

Factual narrative

On March 25, 2022, about 1613 eastern daylight time, a Diamond DA-40NG, N471BL, was substantially damaged when it was involved in an accident near Johnston Regional Airport (JNX), Smithfield, North Carolina. The flight instructor and pilot receiving instruction were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the flight instructor and pilot receiving instruction, they conducted a preflight inspection of the airplane, with no anomalies noted, before departing from runway 21 at JNX. Review of radar data revealed that the airplane climbed to an altitude of about 650 ft while turning left. The flight instructor stated that she “heard a weird noise come from the engine” and saw the rpm gauge drop. Shortly afterward, the flight instructor directed the pilot receiving instruction to turn back to the airport, and the engine lost total power while in the turn. The flight instructor attempted to restart the engine while the airplane descended but was unsuccessful. The airplane subsequently impacted trees about 1 mile from the departure end of the runway, resulting in substantial damage to the fuselage. In addition, both wings and the empennage were fractured from the impact. A postaccident examination of the engine revealed that engine valvetrain was not timed correctly and that the resulting misalignment resulted in the piston striking the valve. The valve head had subsequently separated and fallen into the cylinder. Examination of the maintenance logbooks revealed that the cylinder head and exhaust camshaft had been replaced the day before the accident flight. According to the flight instructor, shortly after takeoff, she heard a “weird” noise coming from the engine and noted a drop in engine rpm. The flight instructor directed the pilot receiving instruction to turn back toward the airport; however, the engine lost all power, and the airplane impacted trees about 1 mile from the departure end of the runway. The airplane sustained substantial damage to the wings, fuselage, and empennage. A postaccident examination of the engine revealed that the engine valvetrain was not timed correctly and that the misalignment resulted in a piston striking a valve. The valve head had separated and fallen into the cylinder, resulting in the total loss of engine power. Examination of the maintenance logbooks revealed that the cylinder head and exhaust camshaft had been replaced the day before the accident flight. Thus, it is likely that the engine’s timing was not set correctly after this maintenance. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12

NTSB Findings

FAA avdata. C = Cause, F = Factor.

  • — Personnel issues-Action/decision-Action-Incorrect action performance-Maintenance personnel
  • — Aircraft-Aircraft power plant-Engine (reciprocating)-Recip eng cyl section-Incorrect service/maintenance
  • — Aircraft-Aircraft power plant-Engine (reciprocating)-Recip eng cyl section-Failure

Verbatim from NTSB's published report. Source file NTSB_2022_ERA22LA169.txt. Findings + structured fields enriched from FAA avall.mdb. Full investigation docket on data.ntsb.gov ↗.

Related research

Matched on aircraft type or causal vocabulary (maintenance). All research papers