# NTSB CEN15LA270: Piper PA28-200, N872CS, Jonesboro, AR, June 10, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 10, 2015, 05:40 local (10:40 UTC) - Place: Jonesboro, AR - Coordinates: 35.831665, -90.646385 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.8317&lon=-90.6464&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report October 3, 2016 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration; LIT FSDO - NTSB case key (mKey): 91362 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN15LA270 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91362/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91362 - Page: https://openairdocs.org/ntsb/CEN15LA270 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: replacement](https://openairdocs.org/ntsb-findings/02062020): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28R-200, 1 case](https://openairdocs.org/ntsb-findings/02062020/cases.md?model=7102811), [All aircraft, 70 cases](https://openairdocs.org/ntsb-findings/02062020/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28R-200, 4 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=7102811), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-28R-200, 3 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=7102811), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not specified (probable cause); cases with it: [Piper PA-28R-200, 3 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=7102811), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Object/animal/substance: pole](https://openairdocs.org/ntsb-findings/03022010): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28R-200, 3 cases](https://openairdocs.org/ntsb-findings/03022010/cases.md?model=7102811), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/03022010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Piper PA-28R-200, 7 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=7102811), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-climb to cruise: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338); cases with it: [Piper PA-28R-200, 1 case](https://openairdocs.org/ntsb-events/338/sequence.md?model=7102811), [All aircraft, 563 cases](https://openairdocs.org/ntsb-events/338/sequence.md) - [Enroute-climb to cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Piper PA-28R-200, 6 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=7102811), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Enroute-climb to cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Piper PA-28R-200, 32 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102811), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Piper PA-28R-200, 32 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102811), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28R-200, 45 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102811), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N872CS-2018-08-10), registration cancelled 2018-08-10, S/N 28R-7635304, built 1976 (OpenAirDocs) - Reported make and model: PIPER PA28-200 - Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7635304 - Year built: 1976 - Airframe hours: 3831.5 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; injuries: none; 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 - Pilot-rated passenger; age 18; injuries: none; 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 ## 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 20150610007649A](https://openairdocs.org/incident/20150610007649A), Jun 10, 2015: Piper PA-28R-200, Jonesboro, AR, Destroyed. On 06/10/2015 N872CS departed from Jonesboro Airport, Jonesboro Arkansas, aircraft was being operated by a private pilot with a valid 2nd class medical. The… ## Docket (4 files) The files NTSB released with the investigation on August 8, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91362. 5.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 5.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442955&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot Statement (item 2, .PDF, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442956&FileExtension=.PDF&FileName=Pilot%20Statement-Master.PDF - Correspondence with Pilot (item 3, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442957&FileExtension=.PDF&FileName=Correspondence%20with%20Pilot-Master.PDF - Service Letter 910 (item 4, .PDF, 180 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442958&FileExtension=.PDF&FileName=Service%20Letter%20910-Master.PDF 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.