# NTSB CEN16LA227: Piper PA 28R-200, N9336N, Bowie, TX, June 20, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 19, 2016, 20:45 local (Jun 20, 2016, 01:45 UTC) - Place: Bowie, TX - Coordinates: 33.601665, -97.775558 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.6017&lon=-97.7756&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-descent: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report May 1, 2017 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 93422 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN16LA227 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93422/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93422 - Page: https://openairdocs.org/ntsb/CEN16LA227 ## Probable cause The inadequate maintenance and inspection of the throttle control arm, which resulted in its in-flight separation and the subsequent loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine fuel and control: fuel controlling system](https://openairdocs.org/ntsb-findings/01057320): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-28R-200, 1 case](https://openairdocs.org/ntsb-findings/01057320/cases.md?model=7102811), [All aircraft, 59 cases](https://openairdocs.org/ntsb-findings/01057320/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-descent: 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-descent: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Piper PA-28R-200, 9 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7102811), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28R-200, 30 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102811), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The commercial pilot reported that he had just completed a cross-country flight and had been cleared for the approach when, during the descent, the engine did not respond when he pulled back on the throttle. When the pilot enriched the fuel/air mixture, the manifold pressure decreased, and the engine lost power. The pilot conducted a forced landing to a field, during which the airplane's wing sustained substantial damaged. The examination of the engine revealed that the throttle control arm, which was original hardware to the airplane, was separated from the joint assembly. Additionally, the female end of the throttle arm exhibited elongation at the linkage attachment point and was consistent with wear developing over time. An examination of the airplane, engine, and remaining systems revealed no other anomalies that would have precluded normal operation. The airplane manufacturer had issued a nonmandatory service letter (SL) recommending that the throttle arm and joint assembly be replaced with a new refinement kit if any indication of wear existed; a review of the engine logbooks found no record of compliance with the SL. Although the pilot reported that the airplane's last inspection was an annual inspection, he did not provide the date of the inspection, and it was not noted in the logbook. Given the condition of the throttle linkage attachment, it is likely that the inspection of the throttle linkage attachment was either not performed or was inadequate. Investigators were unable to determine what the exact state of the throttle arm was at the last inspection. ## Factual narrative On June 19, 2016, about 2045 central daylight time, a Piper PA 28R-200 airplane, N9336N, was substantially damaged during a forced landing to a field near Bowie, Texas. The commercial pilot and two passengers were not injured. The airplane was registered to and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 on an instrument flight rules flight plan. Night visual meteorological conditions prevailed for the personal flight. The flight departed Epply Airfield (OMA), Omaha, Nebraska, about 1615 and was en route to Bowie Municipal Airport (0F2), Bowie, Texas. According to the written statement submitted to the National Transportation Safety Board (NTSB) by the pilot, he had been cleared for the RNAV 17 approach to 0F2 with a descent to 4,000 feet mean sea level (msl). The pilot reported that he "pulled back the throttle with no response from the engine." He reported the situation to air traffic control but stated that it was manageable and did not declare an emergency. About four miles from the airport the pilot enrichened the engine's fuel/air mixture at which time the manifold pressure decreased and the engine lost power. A line of trees and a small lake were in front of the flight path so the pilot elected to perform a forced landing towards a road and open field. According to the Federal Aviation Administration (FAA) inspector who responded to the accident, the airplane's right wing sustained substantial damage during the forced landing. And examination of the engine found that the throttle control arm was separated from the joint assembly. Further examination revealed that the throttle control arm was original hardware to the airplane (part number 31747-00). The female end of the throttle arm exhibited elongation at the attachment point. An examination of the airframe, engine, and remaining systems revealed no other anomalies that would have precluded normal operation. Piper Aircraft Corporation service Letter No. 747, titled 'Inspection of Throttle and Mixture Control Attachments', dated May 28, 1975, recommends that the throttle arm and joint assembly be replaced with a new refinement kit if any indication of wear existed. The Service Letter noted "careful inspection of throttle and mixture control attachments is normal maintenance and is a requirement of both standard Piper Period Inspections and the Piper Program Inspection Procedures." According to the FAA inspector, he examined the logbooks and found no record of compliance with this service letter. According to the accident report form submitted by the pilot, the last inspection performed was an annual type; however, no date for that inspection was provided. Investigators were unable to determine why the service letter was not complied with or what the exact state of the throttle arm was at the last inspection. ## Aircraft - Registration: [N9336N](https://openairdocs.org/deregistered/N9336N-2018-06-08), registration cancelled 2018-06-08, S/N 28R-35036, built 1969 (OpenAirDocs) - Reported make and model: PIPER PA 28R-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-35036 - Year built: 1969 - Engines: LYCOMING IO360 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Departed: KOMA, Omaha, NE - Destination: 0F2, Bowie, TX - Flight plan: IFR - Equipment: Onboard weather, Handheld GPS, Electronic flight bag or handheld device, Auto-pilot, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; injuries: none; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review August 17, 2015; seat: right; restraint: 4-point; flight hours: 1,380 total, 390 in this make and model, 1,014 as pilot in command, 316 in the last 90 days, 103 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 100° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 72 °F - Altimeter: 30.12 inHg - Observed at: 0F2 ## 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 20160619010499A](https://openairdocs.org/incident/20160619010499A), Jun 19, 2016: Piper PA-28R-200, Bowie, TX, Substantial damage. On June 19, 2016, about 2000 central time, a Piper PA-28R-200, N9336N, while on approach to OF2 (Bowie municipal airport, TX), lost throttle control and landed… ## Docket (5 files) The files NTSB released with the investigation on February 16, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93422. 3.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449305&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot's Statement (item 2, .PDF, 202 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449306&FileExtension=.PDF&FileName=Pilot%27s%20Statement-Master.PDF - FAA Inspector Statement (item 3, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449307&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF - Report Photographs (item 4, .PDF, 2 photos, 504 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449308&FileExtension=.PDF&FileName=Report%20Photographs-Master.PDF - Piper Service Letter 0747 (item 5, .PDF, 150 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449309&FileExtension=.PDF&FileName=Piper%20Service%20Letter%200747-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.