WPR14LA249
2014-06-15 · Quincy, California, United States · None · 1 aircraft · Status: Completed
Airport 2O1
Current FAA registration · N4931L
- Make / Model
- PIPER PA-28-180
- Year of manufacture
- 1967 · 47 years old at event
- Engine
- LYCOMING O&VO-360 SER (180 hp)
- Seats / Engines
- 4 seats · 1 engine
- ADS-B equipped
- Yes — Mode-S A61DC3
Source: FAA Aircraft Registry (releasable master file).
Aircraft involved
Probable cause & findings
The partial loss of engine power during takeoff due to the separation of the exhaust baffling, which resulted in a partial blockage of airflow to the engine. Contributing to the accident was maintenance personnel’s inadequate inspection of the exhaust system during the airplane’s most recent maintenance.
Factual narrative
On June 15, 2014, about 1110 Pacific daylight time, a Piper 28-180, N4931L, experienced a partial loss of engine power after takeoff from Gansner Field Airport (2O1), Quincy, California. The certified flight instructor and three passengers were uninjured, and the airplane sustained substantial damage. The airplane was registered to a private party and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight, and no flight plan was filed. The pilot reported that he took off with 10 degrees of flaps. During the initial climb, the pilot retracted the flaps and the airplane started to lose altitude. He extended flaps again, and the airplane continued to climb, but once he retracted them a second time the airplane descended. The pilot realized the airplane would not climb and elected to make a precautionary landing onto a nearby field. During final approach, the stabilator impacted a fence post, before landing uneventfully. A postaccident examination by a Federal Aviation Administration inspector revealed compression on all four cylinders. The intake system was examined and revealed no restrictions or damaged components. The carburetor float bowl was removed and the fuel inside appeared uncontaminated. A light was shined in the forward exhaust pipe and it appeared to be partially blocked. Examination of the aft exhaust pipe revealed it was also partially blocked. Both the forward and aft mufflers were removed; in both cases, the muffler baffling separated from its mount and covered the exhaust port outlet. Review of the engine maintenance logbook records revealed that the most recent annual inspection was completed on May 15, 2014, at an airframe total time of 4,016.55 hours. The pilot reported that, at the time of the accident, the airplane had accumulated about 3 hours of operation since the annual inspection. The front muffler time in service could not be determined. The aft muffler time in service was 1,359 hours. During the inspection, an exterior inspection of the muffler system was performed; however, the exhaust system inspection recommended by Piper was not performed. The Piper Cherokee Service Manual states in part "…a very thorough inspection of the entire exhaust system including exhaust heater shroud assembly, muffler and muffler baffles, stacks, and all exhaust connections and welds must be accomplished at each 100-hour inspection. The possibility of exhaust system failure increases with use. It is recommended that the system be checked more carefully as the number of hours increase, therefore inspection at the 700 hour period, that the exhaust system has been in use would be more critical than ones in the 100 hour period. The system should also be checked carefully before winter operation when the cabin heat will be in use. NOTE: Piper recommends that all PA-28 airplanes be fitted with a new muffler at or near the 1,000 hour period of which the muffler has been used." The pilot reported that, shortly after takeoff, the airplane would not climb; therefore, he chose to make a precautionary landing onto a nearby field. During the final approach, the stabilator impacted a fence post, and the pilot subsequently landed the airplane uneventfully. During a postaccident examination of the exhaust system, the baffles within the muffler assembly were found partially separated and blocking the exhaust ducts, which would have restricted the airflow in the ducts and resulted in a loss of engine power when the airplane reached a higher engine rpm setting during takeoff. No additional mechanical anomalies were observed that would have precluded normal operation. The airplane manufacturer's service manual states, in part, "a very thorough inspection of the entire exhaust system, including the…muffler and muffler baffles, stacks, and all exhaust connections and welds must be accomplished at each 100-hour inspection. The possibility of exhaust system failure increases with use." The airplane's most recent annual inspection, which should have included the items from the 100-hour inspection, occurred about 3 flight hours before the accident. Maintenance records indicated that maintenance personnel inspected the exterior of the muffler system; however, the records did not indicate that maintenance personnel performed the airplane manufacturer-recommended exhaust system inspection. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
FAA avdata. C = Cause, F = Factor.
- C Aircraft-Aircraft power plant-Engine exhaust-(general)-Failure - C
- F Personnel issues-Task performance-Maintenance-Scheduled/routine maintenance-Maintenance personnel - F
- F Aircraft-Aircraft power plant-Engine exhaust-(general)-Not serviced/maintained - F
Verbatim from NTSB's published report. Source file
NTSB_2014_WPR14LA249.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
Search this event elsewhere
External sources are reported, not agency: signal that something happened, not fact about what happened.
- TallyAero Live Wire Aviation press
- NTSB CAROL Agency ↗
- NTSB Docket Agency ↗
- Aviation Safety Network Aviation press ↗
- Kathryn's Report Aviation press ↗
- Aviation Herald Aviation press ↗
- AVweb Aviation press ↗
- Pilots of America Community ↗
- Reddit /r/flying Community ↗
- FlightAware Aviation press ↗
- AOPA accident database Aviation press ↗
- Google News News ↗
- DuckDuckGo News ↗
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…