# NTSB ATL89LA178: Piper PA-32RT-300T, N2153K, Columbus, OH, July 12, 1989

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: July 11, 1989, 22:05 local (Jul 12, 1989, 02:05 UTC)
- Place: Columbus, OH
- Coordinates: 39.969161, -83.129516 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=39.9692&lon=-83.1295&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 3 uninjured
- Status: Completed, report June 25, 1992
- Report: Approved by Office Director
- NTSB case key (mKey): 8045
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL89LA178
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8045/pdf
- Page: https://openairdocs.org/ntsb/ATL89LA178

## Probable cause

THE IMPROPER INSTALLATION OF THE PROPELLER GOVERNOR IDLER-GEAR SHAFT RETAINING SET-SCREW, WHICH LED TO AN ENGINE OIL LEAK AND RESULTED IN A LOSS OF ENGINE POWER; AND THE REDUCTION OF THE PILOT'S ABILITY TO SEE OUTSIDE THE AIRPLANE DUE TO OIL ON THE WINDSHIELD.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power(partial) - mech failure/malf, cruise - normal
  - reduction gear assy,accessory drive shaft - not secured (cause)
  - maintenance,service bulletin/letter - not followed, other maintenance personnel (cause)
  - maintenance,installation - improper, other maintenance personnel (cause)
  - engine assembly,other - chafed (cause)
  - fluid,oil - leak (cause)
  - fluid,oil - starvation (cause)
- Forced landing, descent - emergency
- Hard landing, landing
  - light condition - dark night (contributing factor)
  - window,flight compartment window/windshield - dirty(foggy) (cause)
  - visual lookout - restricted, pilot in command (cause)

## Analysis

THE ENGINE DEVELOPED A MASSIVE OIL LEAK DURING CRUISE & THE ENGINE LOST POWER. THE PLT MADE A FORCED LDG AT THE NEAREST ARPT. THE PLT WAS UNABLE TO CLEARLY SEE THE RWY DUE TO OIL COVERING THE WINDSHIELD, AND MADE A HARD LDG AS A RESULT. THE LDG GEAR COLLAPSED DURING THE LDG. POST-ACCIDENT EXAM OF THE ENGINE REVEALED THAT AN IMPROPER LENGTH SET-SCREW HAD BEEN INSTALLED TO RETAIN THE PROP GOVERNOR IDLER-GEAR SHAFT IN PLACE; THE SCREW WAS TOO SHORT, WHICH PREVENTED THE PROPER USE OF STAKING TO SECURE THE SCREW IN PLACE AGAINST THE SHAFT. THE SCREW BACKED OFF AND ALLOWED THE NORMALLY-STATIONARY SHAFT TO ROTATE. THE SHAFT CUT THROUGH AN ACCESS PLUG ON THE FRONT OF THE ENGINE, WHICH ALLOWED OIL TO DRAIN OVERBOARD. INVESTIGATION REVEALED THAT THE SCREW WAS MOST LIKELY INSTALLED WHEN THE IDLER GEARS WERE REPLACED DURING A SUDDEN-STOPPAGE INSPECTION. LYCOMING SERVICE INSTRUCTION 1343 DESCRIBES HOW THE LENGTH OF THE SET SCREW SHOULD BE DETERMINED, AND HOW THE SCREW SHOULD BE INSTALLED.

## Aircraft

- Registration: [N2153K](https://openairdocs.org/deregistered/N2153K-1990-04-27), registration cancelled 1990-04-27, S/N 32R7987086 (OpenAirDocs)
- Reported make and model: PIPER PA-32RT-300T (PA-32RT-30)
- Registry model: [Piper PA-32RT-300T](https://openairdocs.org/model/piper-pa-32rt-300t) (registry code 7103216) (OpenAirDocs)
- Category: Airplane
- Serial number: 32R7987086
- Airframe hours: 1907
- Engines: LYCOMING TIO-540-S1AD 300 horsepower reciprocating
- Damage: Substantial damage
- Flight: Business, Part 91
- Operator: Ferguson Lee, Inc.
- Registered owner: Ferguson Lee, Inc
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, April 12, 1989, 60 hours before
- Departed: CMH, COLUMBUS, OH
- Destination: BFR, BEDFORD, IN
- Flight plan: IFR
- Airport: 2I4, Bolton Field, runway 22, 5,200 × 100 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 51; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; flight hours: 3,600 total, 250 in this make and model, 3,400 as pilot in command, 206 in the last 90 days, 80 in the last 30 days, 5 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Night/dark
- Visibility: 7 statute miles
- Lowest ceiling: 8,000 ft overcast
- Temperature: 72 °F
- Altimeter: 30.00 inHg

## 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 19890711024859A](https://openairdocs.org/incident/19890711024859A), Jul 11, 1989: Piper PA32RT300T, Columbus, OH, Substantial damage. Smoke in cockpit and oil on windshield. Gear collapsed on hard forced landing. Governor idler gear set screw loose.

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.

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