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 ↗.
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Related research
Matched on aircraft type or causal vocabulary (maintenance). All research papers
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA) From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- Semantic Scholar 2026 · Article (Reliability Engineering & System Safety) Understanding human error in military aviation maintenance: The role of Performance shaping factors, cognitive workload and error orientation
- Semantic Scholar 2025 · Article (Applied Sciences) Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Semantic Scholar 2024 · Article (Defence Science Journal) Modelling of Human Factors in Aviation Maintenance Using HFACS ME Human Factors Analysis and Classification System Maintenance Extension and Bayesian Network
Aircraft maintenance is a complex task involving a skilled human workforce, spare parts, and various other resources. Human factors are an inherent element of the human workforce.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER) A New Trajectory in UAV Safety: Leveraging Reinforcement Learning for Distance Maintenance Under Wind Variations
In the field of aviation, safety is a critical cornerstone, and the operation of Unmanned Aerial Vehicle (UAV) systems is deeply connected with this principle.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER) Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…