# NTSB ANC18LA006: Piper PA 32R-300, N4213F, Dawsonville, GA, October 30, 2017 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: October 30, 2017, 08:26 local (12:26 UTC) - Place: Dawsonville, GA - Coordinates: 34.434444, -84.176666 - Nearby events: https://openairdocs.org/map.md?lat=34.4344&lon=-84.1767&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report November 15, 2018 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - Parties: FAA - NTSB case key (mKey): 96269 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC18LA006 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96269/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96269 - Page: https://openairdocs.org/ntsb/ANC18LA006 ## Probable cause The failure of the pilot, who was not a certified mechanic, to tighten the B-nut on a remotely mounted oil filter line, which resulted in oil exhaustion, a total loss of oil pressure, and a subsequent total loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Piper PA-32R-300, 3 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=7103213), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) - [Eng oil sys (airframe furnish): eng oil dist (airframe furn)](https://openairdocs.org/ntsb-findings/01057920): Aircraft › Aircraft power plant · Inadequate inspection (probable cause); cases with it: [Piper PA-32R-300, 1 case](https://openairdocs.org/ntsb-findings/01057920/cases.md?model=7103213), [All aircraft, 18 cases](https://openairdocs.org/ntsb-findings/01057920/cases.md) - [Eng oil sys (airframe furnish): eng oil dist (airframe furn)](https://openairdocs.org/ntsb-findings/01057920): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-32R-300, 1 case](https://openairdocs.org/ntsb-findings/01057920/cases.md?model=7103213), [All aircraft, 18 cases](https://openairdocs.org/ntsb-findings/01057920/cases.md) - [Maintenance: replacement](https://openairdocs.org/ntsb-findings/02062020): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-32R-300, 1 case](https://openairdocs.org/ntsb-findings/02062020/cases.md?model=7103213), [All aircraft, 70 cases](https://openairdocs.org/ntsb-findings/02062020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-32R-300, 14 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7103213), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Enroute: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-32R-300, 11 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7103213), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The private pilot was conducting a personal flight and reported that, while the airplane was climbing after takeoff, the engine began to run roughly and lose power. The pilot began a descent for an emergency landing and, during the descent, he sensed a "bad" engine vibration, which was followed by a complete loss of engine power. The pilot selected an area on an asphalt-covered automobile racetrack to make a forced landing, which resulted in substantial damage to the airplane's wings and fuselage. A postaccident engine examination revealed a crack in the accessory case and a large hole in the crankcase near the No. 6 cylinder pad. A subsequent internal examination revealed damage to the engine's internal components, including the main bearings and the No. 6 connecting rod, that was consistent with oil exhaustion. The airplane was equipped with a remotely mounted oil filter. A B-nut on one of the oil filter lines was found to be loose with about 2 ½ threads showing. The B-nut was tightened by hand and rotated about 1 ¾ turns, which resulted in about ½ thread showing. The pilot stated that he was not an airframe and powerplant mechanic but that he had replaced the oil line about 1 week before the accident. The accident flight was the first flight after that maintenance. ## Factual narrative On October 30, 2017, about 0826 eastern daylight time, a Piper PA-32R-300 airplane, N4213F, sustained substantial damage during a forced landing on an asphalt-covered automobile race track about 4 miles west-northwest of Dawsonville, Georgia. The private pilot sustained serious injuries. The airplane was registered to Peavy LLC and was being operated as a 14 Code of Federal Regulations Part 91 instrument flight rules (IFR) flight. Visual meteorological conditions prevailed and an IFR flight plan had been filed. The flight departed Gainesville, Georgia (GVL) about 0807, destined for Gary, Indiana (GYY). According to the pilot, while climbing through 8,000 ft mean sea level (msl) to an assigned altitude of 10,000 ft msl, he heard a sound consistent with a propeller overspeed, which lasted about 5 seconds before returning to normal. Coinciding with the sound, was a low oil quantity light and a reading of zero on the oil pressure gauge. After declaring an emergency, the pilot began a descent for an emergency landing. As the airplane descended through about 5,000 ft msl, the pilot heard a loud "pop or bang" and saw a puff of smoke emit from under the engine cowling, and smoke entered the cockpit through the cabin heat system. Around 3,500 ft msl, the pilot tried to add some power before sensing a "bad vibration" that felt as if a propeller blade had separated. About the same time as the vibration, the engine lost all power. Seeing an asphalt-covered automobile racetrack below, the pilot selected one of the straight sections of track for landing. As the airplane neared the surface, a white truck moved in the way, and the pilot veered the airplane left to avoid a collision. Following the maneuver, the airplane's right wing struck a dirt berm, resulting in substantial damage to the wings and fuselage. An on-site examination of the airplane by a Federal Aviation Administration (FAA) aviation safety inspector revealed that the bottom of the fuselage was coated in oil and the engine crank case was fractured at the upper aft attach bolts of the number six cylinder. All three propeller blades were present, with only one blade exhibiting signs of damage. The damaged blade was bent aft with no significant signs of leading edge damage or scaring. The two remaining blades were free of impact damage. The airplane was equipped with a Lycoming IO-540 series engine, which was examined on November 16, 2017. The engine is a six-cylinder, air cooled, direct drive, horizontally opposed, normally aspirated, fuel injected, internal combustion engine. Extensive fracturing of the engine crankcase above the #6 cylinder was present. The engine was disassembled for inspection and the crankcase was opened. The #3 and #4 main bearings on both the left and right side of the crankcase were wiped with copper flashing and bearing material was extruding. The connecting rod and crankshaft journals for the #5 cylinder exhibited signs consistent with thermal damage with the bearingextruded. The connecting rod and crankshaft journals for the #6 cylinder were fragmented, however both connecting rod bolts remained in place and attached. The piston and wrist pin remained attached with about 3 inches of the fractured connecting rod. The airplane was equipped with an Air Wolf remote mounted oil filter (P/N 0FB 10). The kit consists of two hoses, an adapter that mounts to the engine's accessory case, and an oil filter bracket that mounts to the airplane's firewall. When the kit is installed, the oil filter is remotely mounted to the airplane's firewall. A B-nut on one of the remote mounted oil filter lines was observed to be loose with about 2 ½ threads showing. The B-nut was tightened by hand and rotated about 1 and ¾ turns with about ½ thread showing. According to the pilot, he was not an airframe or powerplant mechanic, but he said that he replaced the line about a week before the accident, and this was the first flight since that installation. The closest official weather observation station is GVL, which is located about 20 miles southeast of the accident site. At 0753, a METAR was reporting, in part, wind 270° at 8 knots; visibility 10 statute miles; clouds and ceiling clear; temperature 36° F; dew point 28° F; altimeter 29.96 inches of Mercury. ## Aircraft - Registration: [N4213F](https://openairdocs.org/deregistered/N4213F-2019-01-16), registration cancelled 2019-01-16, S/N 32R-7680432, built 1976 (OpenAirDocs) - Reported make and model: PIPER PA 32R-300 - Registry model: [Piper PA-32R-300](https://openairdocs.org/model/piper-pa-32r-300) (registry code 7103213) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 32R-7680432 - Year built: 1976 - Airframe hours: 5527.91 - Engines: LYCOMING IO540-K165D 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 31, 2017, 15 hours before - Departed: GVL, GAINESVILLE, GA - Destination: GYY, GARY, IN - Flight plan: VFR/IFR - Equipment: Electronic multifunction display, Stall warning system, ADS-B, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: serious; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review November 15, 2016; seat: left; flight hours: 1,300 total, 1,000 in this make and model, 1,200 as pilot in command, 25 in the last 90 days, 6 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 270° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 36 °F, dew point 28 °F - Altimeter: 29.95 inHg - Turbulence: Unknown - Observed at: KGVL, 20 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20171030020459A](https://openairdocs.org/incident/20171030020459A), Oct 30, 2017: Piper PA-32R-300, Dawsonville, GA, Destroyed. The aircraft was traveling thru 8000 feet and was estimated to be traveling in a north westerly direction. The pilot reports at 8000 feet engine indicated what… ## Docket (5 files) The files NTSB released with the investigation on September 23, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96269. 7.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 725 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466814&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation (item 2, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466815&FileExtension=.PDF&FileName=Record%20of%20Conversation-Master.PDF - Loose B-Nut Video (item 3, MOV, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466816&FileExtension=mov&FileName=Loose%20B-Nut%20Video-Master - Photos (item 4, .PDF, 3 photos, 197 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466817&FileExtension=.PDF&FileName=Photos-Master.PDF - Air Traffic Control Audio (item 5, MP4, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466818&FileExtension=mp4&FileName=Air%20Traffic%20Control%20Audio-Master From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.