# NTSB CEN18LA065: Piper PA-28-201T, N555WM, Versailles, MO, December 19, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: December 19, 2017, 11:45 local (17:45 UTC) - Place: Versailles, MO - Coordinates: 38.428333, -92.875274 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.4283&lon=-92.8753&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report November 15, 2018 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Kansas City FSDO - NTSB case key (mKey): 96562 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN18LA065 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96562/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96562 - Page: https://openairdocs.org/ntsb/CEN18LA065 ## Probable cause The total loss of engine power due to fuel starvation when the cap fitting came off the inlet tee fitting on the throttle body/fuel metering unit. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel distribution](https://openairdocs.org/ntsb-findings/01022820): Aircraft › Aircraft systems · Damaged/degraded (probable cause); cases with it: [Piper PA-28-201T, 1 case](https://openairdocs.org/ntsb-findings/01022820/cases.md?model=7102819), [All aircraft, 141 cases](https://openairdocs.org/ntsb-findings/01022820/cases.md) - [Fuel system: fuel distribution](https://openairdocs.org/ntsb-findings/01022820): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-28-201T, 1 case](https://openairdocs.org/ntsb-findings/01022820/cases.md?model=7102819), [All aircraft, 141 cases](https://openairdocs.org/ntsb-findings/01022820/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: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330); cases with it: [Piper PA-28-201T, 1 case](https://openairdocs.org/ntsb-events/330/sequence.md?model=7102819), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) - [Takeoff: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-28-201T, 2 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102819), [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-28-201T, 2 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102819), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The private pilot was going to perform a local flight for the first time after an overhauled engine was installed on the airplane. During engine ground operations, no leaks were noted, and the engine operated normally. After takeoff, the pilot flew the airplane around the airport traffic pattern and accomplished a touch-and-go landing. During the climbout, at 400 to 500 ft above ground level, the engine lost total power. The pilot conducted a forced landing to a field. During the landing roll, the airplane's left wing struck a metal fence post, which resulted in substantial damage to the airplane. A postaccident examination revealed that the inlet tee fitting on the throttle body/fuel metering unit was missing a cap fitting, which was subsequently found between the Nos. 3 and 5 cylinders. After the cap fitting was reinstalled, the engine was restarted and ran normally. The mechanic who installed the overhauled engine stated that the cap fitting was in its proper place during the installation of the engine and that he had not disturbed the cap fitting during the maintenance that was performed before the maintenance check flight. The repair station's quality control manager reported that an inspector checked all of the engine fittings to verify that they were secure. During the engine test run, the tee fitting was not disturbed because it was not used to attach the gauge for the fuel system checks, and the engine met all performance objectives of the test run. The engine experienced a total loss of power due to fuel starvation when the cap fitting came off the inlet tee fitting on the throttle body/fuel metering unit. However, the available evidence was not sufficient to determine how the cap fitting became loose and displaced from its installed location. ## Factual narrative On December 19, 2017, about 1145 central standard time, a Piper PA-28-201T, N555WM, impacted terrain and obstacles during a forced landing after takeoff from the Roy Otten Memorial Airfield (3VS), near Versailles, Missouri. The pilot was not injured; and the airplane sustained substantial damage. The airplane was owned and operated by GPFO LLC under the Title 14 Code of Federal Regulations Part 91 as a maintenance check flight. Visual meteorological conditions prevailed during the flight, which was not operated on a flight plan. The local flight was departing from 3VS at the time of the accident. The pilot stated that an overhauled engine was installed on the airplane and this was the first flight after the engine change. During engine ground operations, no leaks were noted, and the engine operated normally. The pilot accomplished multiple ground runs including a takeoff/abort run. He accomplished the before takeoff checklist and everything was "in the green." The pilot reported that he departed on runway 25, flew once around the airport traffic pattern, and accomplished a touch-and-go. During climbout at 400-500 ft above ground level, a loud bang was heard by a witness on the ground (the pilot did not hear the bang) and the engine lost total power. The pilot conducted a forced landing to a field about 3/4 miles from the airport. During the landing roll, the airplane's left wing a struck metal fence post which resulted in substantial damage. The pilot and the mechanic who performed the engine installation examined the engine at the accident site and noticed a cap fitting was missing from the inlet tee fitting on the throttle body/fuel metering unit. The cap fitting was found between the No. 3 and No. 5 cylinders. After reinstalling the cap fitting, the engine was restarted and ran normally. With the assistance from the local police, the pilot taxied the airplane back to the airport using local roads. The mechanic who installed the overhauled engine stated that the cap fitting was in place when he received the overhauled engine from the repair station. He stated that he had not disturbed the cap fitting during the installation of the engine or during maintenance performed before the maintenance check flight. Although the engine manufacturer recommended that the fuel injection system should be adjusted after an engine installation, the mechanic reported that the engine was operating normally, and he did not perform the maintenance procedures contained in the Continental Motors Service Information Directive SID97-3G. The repair station's quality control manager reported that the fuel system was removed from the engine and overhauled in the component shop. The fuel system, with the cap fitting installed, was tested before it was reinstalled on the engine. Upon completion of the fuel system overhaul and before the engine went to the engine test cell for the final engine run testing, an inspector checked that all the engine fittings were secure.During the engine test run in the test cell, the tee fitting was not used to attach the gauge for the fuel system checks. The quality control manager stated that the cap fitting had not been leaking during the engine runs in the test cell, and that the engine met all the performance objectives without further fuel system adjustments. ## Aircraft - Registration: [N555WM](https://openairdocs.org/aircraft/N555WM), registered now, S/N 28-7921047, built 1979 (OpenAirDocs) - Reported make and model: PIPER PA-28-201T - Registry model: [Piper PA-28-201T](https://openairdocs.org/model/piper-pa-28-201t) (registry code 7102819) (OpenAirDocs) - Registry engine: [Continental TSIO-360 series](https://openairdocs.org/engine/continental-tsio-360-series) (registry code 17019, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7921047 - Year built: 1979 - Engines: Continental Motors TSIO-360-FB 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 19, 2017, 1,476 hours before - Departed: 3VS, Versailles, MO - Destination: 3VS, Versailles, MO - Airport: 3VS, Roy Otten Memorial Airfield, runway 25, 2,805 × 39 ft, asphalt - Equipment: Stall warning system, Handheld GPS, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: none; private; airplane ratings: single-engine land, single-engine sea; medical: class 3, with waivers/limitations; seat: left; restraint: 3-point; flight hours: 385 total, 266 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 52 °F, dew point 45 °F - Altimeter: 30.06 inHg - Observed at: LXT, 93 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 20171219023309A](https://openairdocs.org/incident/20171219023309A), Dec 19, 2017: Piper PA-28-201T, Versailles, MO, Substantial damage. After departing on runway 25, the engine lost power when the aircraft was at approximately 400 AGL. The pilot was able to land in a farm field about 3/4 mile… ## Docket (7 files) The files NTSB released with the investigation on June 19, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96562. 5.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464237&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot Statement (item 2, .PDF, 379 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464238&FileExtension=.PDF&FileName=Pilot%20Statement-Master.PDF - Mechanic's Statement (item 3, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464239&FileExtension=.PDF&FileName=Mechanic%27s%20Statement-Master.PDF - NTSB Record of Conversations (item 4, .PDF, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464240&FileExtension=.PDF&FileName=NTSB%20Record%20of%20Conversations-Master.PDF - Engine Maintenance Manual Excerpts (item 5, .PDF, 464 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464241&FileExtension=.PDF&FileName=Engine%20Maintenance%20Manual%20Excerpts-Master.PDF - Aerial Image of Accident Site (item 6, .PDF, 260 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464242&FileExtension=.PDF&FileName=Aerial%20Image%20of%20Accident%20Site-Master.PDF - Photo of Cap Fitting on Fuel System Test Port (item 7, .PDF, 1 photo, 169 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464243&FileExtension=.PDF&FileName=Photo%20of%20Cap%20Fitting%20on%20Fuel%20System%20Test%20Port-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.