CEN15LA270

NTSB accident investigation · Piper PA28-200 · Jonesboro, AR · June 10, 2015

Accident · No injuriesLimited investigationFinal report
Date
June 10, 2015, 05:40 local (10:40 UTC)
Place
Jonesboro, AR
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N872CSPiper PA28-200
Defining event
Enroute-climb to cruise: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report October 3, 2016
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration; LIT FSDO
FAA report
20150610007649A
Case key
91362

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

Maintenance personnel's improper engine oil drain valve installation, which led to engine oil exhaustion and the subsequent loss of engine power after takeoff at an altitude too low for the pilot to execute a forced landing in a suitable area.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Maintenance: replacementPersonnel issues › Task performance · Maintenance personnelPiper PA-28R-200: 1 caseAll aircraft: 70 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelPiper PA-28R-200: 4 casesAll aircraft: 320 casesProbable cause
Engine (reciprocating): recip eng oil sysAircraft › Aircraft power plant · Incorrect service/maintenancePiper PA-28R-200: 3 casesAll aircraft: 130 casesProbable cause
Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Not specifiedPiper PA-28R-200: 3 casesAll aircraft: 1,310 casesProbable cause
Object/animal/substance: poleEnvironmental issues › Physical environment · Contributed to outcomePiper PA-28R-200: 3 casesAll aircraft: 142 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The private pilot was taking off for a personal flight. The pilot reported that, about 3 to 5 minutes after takeoff, the oil light illuminated and that, shortly thereafter, while the airplane was about 1,800 ft mean sea level, the oil pressure gauge indicated 0. About 20 to 30 seconds later, a total loss of engine power occurred. The pilot attempted to return to the departure airport but was unable to reach the runway due to insufficient altitude. The pilot subsequently conducted a forced landing in a parking lot, during which the airplane impacted a sign pole. Examination of the airplane revealed that, during retraction, the nose landing gear (NLG) had contacted and broken the engine oil drain valve, which was the incorrect part number. The airplane manufacturer had previously issued a service letter, which noted that, when the wrong part number drain valve was installed, it was possible that during NLG retraction the valve may contact the NLG drag link, become actuated, and allow the oil to be drained out in flight. The accident flight was the first flight since the drain valve had been replaced the previous day during a 100-hour/annual inspection. Given the evidence, maintenance personnel did not install the correct part number drain valve during the inspection, which resulted in it contacting the NLG and breaking. The oil then drained from the broken valve, which resulted in oil exhaustion and the subsequent loss of engine power.

Factual narrative

On June 10, 2015, at 0540 central daylight time, a Piper PA-28R-200, N872CS, experienced a total loss of engine power due to oil exhaustion during climb after takeoff from Jonesboro Municipal Airport (JBR), Jonesboro, Arkansas. The pilot performed a forced landing to a parking lot where the airplane struck a sign pole. The airplane sustained substantial damage to the right wing and right side of the empennage. The private pilot and a private pilot rated passenger were uninjured. The airplane was registered to C & S Aviation LLC and operated by the pilot under Title 14 Code of Federal Regulations Part 19 as a personal flight. The flight was originating at the time of the accident. The pilot stated that during his preflight inspection of the airplane, there was 8 quarts of engine oil in the engine (Lycoming IO-360-C1C, serial number L-15562-51A). About 3-5 minutes after takeoff from runway 23, the oil light illuminated, and within seconds the oil pressure gauge indicated zero while the airplane was at an altitude of about 1,800 feet mean sea level. The pilot decided to return to JBR and land on runway 5 and about 20-30 seconds later, the engine lost all power. The pilot stated that the airplane was unable to attain the runway 5 due to insufficient airplane altitude. The pilot then performed a forced landing to a parking lot where the airplane right wing contacted sign pole, which spun and flipped the airplane over. According to a Federal Aviation Administration inspector, examination of the airplane revealed that the nose wheel had contacted and broke an oil drain valve during gear retraction. The oil drain valve was the incorrect part number, which was addressed by Piper Aircraft Corporation Service Letter Number 910. The correct part number for the installation was "32 492-172 * VALVE ASSY - Oil drain-(1H50-1)." According to the pilot, the accident flight was the first flight after the oil drain valve had been replaced by an airframe and powerplant mechanic. A June 9, 2015 engine logbook entry stated that the engine received a 100-hour/annual inspection at a tachometer time of 3,831.5 hours and an engine total time of 1,831.5 hours.

Aircraft

Registration
N872CS
Reported as
Piper PA28-200
Category
Airplane
Serial number
28R-7635304
Built
1976
Airframe hours
3,831.5
Engine
Lycoming IO-360-C1C, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Pilot
Registered owner
C & S Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 9, 2015
Departed
JBR · Jonesboro, AR
Destination
SBR · Stillwater, OK
Airport
JBR · Jonesboro Municipal Airport
Equipment
Unknown

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
40
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
December 14, 2014
Seat
Left
Restraint
3-point
Flight hours
273 total · 36 in this make and model · 212 as pilot in command · 51 in the last 90 days · 17 in the last 30 days
Role
Pilot-rated passenger
Age
18
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
May 15, 2015
Seat
Right
Restraint
3-point
Flight hours
77 total · 9 in this make and model · 69 as pilot in command · 45 in the last 90 days · 31 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
68 °F, dew point 66 °F
Altimeter
29.86 inHg
Observed at
JBR, 1 nm away

Docket · 4

The files NTSB released with the investigation on August 8, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.6 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.