# NTSB CEN19LA132: Piper PA28R, N41AT, Prairieville, LA, April 3, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: April 3, 2019, 10:00 local (15:00 UTC) - Place: Prairieville, LA - Coordinates: 30.346389, -91.029441 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.3464&lon=-91.0294&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA Flight Standards - ADs cited in the narratives: [AD 81-11-02 R1](https://openairdocs.org/ad/81-11-02-R1) (OpenAirDocs) - NTSB case key (mKey): 99348 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19LA132 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99348/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99348 - Page: https://openairdocs.org/ntsb/CEN19LA132 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-28R-200, 8 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=7102811), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md) - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-28R-200, 8 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=7102811), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Piper PA-28R-200, 4 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=7102811), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/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) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); 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: 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 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](https://openairdocs.org/deregistered/N41AT-2020-08-21), registration cancelled 2020-08-21, S/N 28R-7635146, built 1975 (OpenAirDocs) - Reported make and model: Piper PA28R (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-7635146 - Year built: 1975 - Airframe hours: 4754 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: serious; 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 ## 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 20190403002469A](https://openairdocs.org/incident/20190403002469A), Apr 3, 2019: Piper PA-28R-200, Prairieville, LA, Minor damage. 04/03/2019 N41AT departed kbtr at 1445Z enroute to kreg at 1500 feet. Pilot declared an emergency due to engine failure 13 miles north of destination. Pilot… ## Docket (10 files) The files NTSB released with the investigation on July 7, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99348. 5.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40473920&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Witness Statement (item 2, .PDF, 181 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40473921&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF - FAA Inspector Statement (item 3, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40473922&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF - Photo of Engine Oil Drain Valve (item 4, .PDF, 157 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40473923&FileExtension=.PDF&FileName=Photo%20of%20Engine%20Oil%20Drain%20Valve-Master.PDF - Maintenance Records -- Airframe (item 5, .PDF, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40473924&FileExtension=.PDF&FileName=Maintenance%20Records%20--%20Airframe-Master.PDF - Maintenance Records -- Engine (item 6, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40473925&FileExtension=.PDF&FileName=Maintenance%20Records%20--%20Engine-Master.PDF - Piper Service Letter No. 910 (item 7, .PDF, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40473926&FileExtension=.PDF&FileName=Piper%20Service%20Letter%20No.%20910-Master.PDF - FAA Airworthiness Directive -- 81-11- (item 8, .PDF, 593 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40473927&FileExtension=.PDF&FileName=FAA%20Airworthiness%20Directive%20--%2081-11--Master.PDF - Piper Cherokee Service Manual -- Excerpt (item 9, .PDF, 716 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40473928&FileExtension=.PDF&FileName=Piper%20Cherokee%20Service%20Manual%20--%20Excerpt-Master.PDF - Curtis Quick Drain Valve -- CCB-37000 (item 10, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40473929&FileExtension=.PDF&FileName=Curtis%20Quick%20Drain%20Valve%20%20--%20CCB-37000-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.