CEN19LA132

NTSB accident investigation · Piper PA28R · Prairieville, LA · April 3, 2019

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
April 3, 2019, 10:00 local (15:00 UTC)
Place
Prairieville, LA
Injuries
1 serious
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N41ATPiper PA28R
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA Flight Standards
FAA report
20190403002469A
Case key
99348

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

Installation of an incorrect engine oil drain valve, which resulted in damage to the valve during landing gear retraction and subsequent engine failure due to oil starvation. Contributing to the accident was the failure of maintenance personnel to comply with the Airworthiness Directive regarding the engine oil drain valve.

Findings · 4

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.

Engine (reciprocating): recip engine power sectionAircraft › Aircraft power plant · Incorrect service/maintenancePiper PA-28R-200: 8 casesAll aircraft: 233 casesProbable cause
Fluids: oilAircraft › Fluids/misc hardware · Fluid levelPiper PA-28R-200: 4 casesAll aircraft: 174 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelPiper PA-28R-200: 4 casesAll aircraft: 320 casesProbable cause

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 pilot was conducting the airplane's first flight following an annual inspection. About 5 minutes after takeoff, the engine started to run rough and seized. The pilot performed a forced landing, during which he sustained serious injuries. Postaccident examination revealed that the engine oil drain valve was damaged when the nose landing gear contacted the valve during gear retraction after takeoff. This resulted in a loss of engine oil and subsequent engine failure due to oil starvation. Further examination revealed that the installed drain valve did not meet manufacturer specifications; the installed valve protruded about 1-1/8 inches from the engine, while the manufacturer-specified valve protruded about 1/2 inch. A review of the airplane maintenance records revealed that the valve was replaced during the annual inspection because it had been leaking. The airframe manufacturer had previously issued a service bulletin regarding installation of an incorrect engine oil drain valve. The Federal Aviation Administration subsequently issued an Airworthiness Directive requiring the replacement of any incorrectly installed valves and placement of a warning placard on the engine mount. The airplane maintenance manual also included a cautionary note regarding the engine oil drain valve and noted the requirement for a warning placard. A warning placard was not present on the accident airplane.

Factual narrative

On April 3, 2019, about 1000 central daylight time, a Piper PA-28R-200 airplane, N41AT, sustained minor damage during a forced landing following a loss of engine power near Prairieville, Louisiana. The pilot was seriously injured. The airplane was registered to and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Day visual meteorological conditions prevailed. The flight was not operated on a flight plan. The flight originated from Baton Rouge Metropolitan Airport (BTR), Baton Rouge, Louisiana, about 0950 and was destined for the Louisiana Regional Airport (REG), Gonzales, Louisiana. The pilot reported that he had picked up the airplane after the annual inspection was completed. About 5 minutes after takeoff, the engine started to run rough and almost immediately seized. He setup for a forced landing on an interstate highway; however, on final approach, the airplane struck a semi-tractor trailer. The airplane subsequently contacted the ground adjacent to the highway and impacted a tree. A postaccident examination performed by a Federal Aviation Administration (FAA) inspector determined that the engine oil drain valve was damaged which had resulted in a loss of engine oil. The valve damage was consistent with contact from the nose landing gear during retraction. Further investigation revealed that the installed drain valve did not correspond to the airframe manufacturer's requirements. The installed valve protruded about 1-1/8 inches from the engine, while the manufacturer specified valve protruded about 1/2 inch. In addition, the required warning placard related to the oil valve installation was not present on the engine mount. A review of the airplane maintenance records revealed that an annual inspection was completed the day before the accident. The entry noted that the oil valve had "stuck open" during the oil change and a new one was installed. It also noted that "clearance with landing gear [was] verified during retract tests." In December 1980, Piper Aircraft issued Service Letter No. 910 which notified owner/operators of the installation of incorrect oil drain valves on PA-28R-200 airplanes. The service letter specifically noted the possibility of damage to the valve during nose landing gear retraction and a loss of engine oil during flight. The service letter recommended inspection of the drain valve to ensure that the correct valve was installed and replacement of any incorrectly installed valves. In addition, the service letter provided for the installation of warning placards on each side of the engine mount in the area of the drain valve in order to advise maintenance personnel. In October 1981, the FAA issued airworthiness directive 81-11-02 R1 requiring inspection of the engine oil drain valves and installation of the warning placards as specified in the previously issued service letter. The current airplane service manual, revision dated January 2008, included a cautionary note regardingthe engine oil drain valve. Specifically, the manual advised personnel to verify that the correct valve was installed and warned that the installation of an incorrect valve may damage the sump or the drain valve. It noted the possibility of a loss of engine oil and engine seizure in such instances. The manual also included the warning placard as part of the engine installation diagram.

Aircraft

Registration
N41AT
Reported as
Piper PA28R (200)
Category
Airplane
Serial number
28R-7635146
Built
1975
Airframe hours
4,754
Engine
Lycoming IO-360-C1C, 200 horsepower, reciprocating
Damage
Minor damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 2, 2019 · 1 hours before
Departed
BTR · Baton Rouge, LA
Destination
REG · Gonzales, LA
Equipment
Electronic flight bag or handheld device, ADS-B, Stall warning system, Auto-pilot

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
63
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
BasicMed, Without waivers/limitations
Last flight review
October 22, 2017
Seat
Left
Restraint
3-point
Flight hours
1,161 total · 952 in this make and model · 1,161 as pilot in command · 11 in the last 90 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
80° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 46 °F
Altimeter
30.29 inHg
Observed at
REG, 11 nm away

Docket · 10

The files NTSB released with the investigation on July 7, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.4 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.