CEN21LA031

NTSB accident investigation · Piper PA28 · Buda, TX · October 21, 2020

Accident · No injuriesClass 3 · LimitedFinal report
Date
October 20, 2020, 20:20 local (Oct 21, 2020, 01:20 UTC)
Place
Buda, TX
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N5932UPiper PA28
Defining event
Enroute: Loss of engine power (total)
Weather
Visual (VMC) · Night
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Flight Standards District Office
FAA report
20201020018759A
Case key
102197

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

An improperly torqued oil line fitting during an engine overhaul, which resulted in oil exhaustion and a total loss of engine power.

Findings · 5

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.

Misc hardware: hoses and tubesAircraft › Fluids/misc hardware · Incorrect service/maintenancePiper PA-28-140: 1 caseAll aircraft: 40 casesProbable cause
Engine (reciprocating): recip eng oil sysAircraft › Aircraft power plant · Incorrect service/maintenancePiper PA-28-140: 1 caseAll aircraft: 130 casesProbable cause
Maintenance: repairPersonnel issues › Task performance · Maintenance personnelPiper PA-28-140: 1 caseAll aircraft: 99 casesProbable cause
Fluids: oilAircraft › Fluids/misc hardware · Fluid levelPiper PA-28-140: 1 caseAll aircraft: 174 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · FailurePiper PA-28-140: 10 casesAll aircraft: 497 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

During a night training flight, the flight instructor and student pilot experienced a total loss of engine power and executed a forced landing onto rough terrain, which damaged the airplane’s right-wing spar. Postaccident examination of the airplane revealed a nearly empty oil reservoir and oil residue on the underside of the fuselage and elevator, with significant thermal damage to the engine. The examination also found a disconnected oil line fitting. No material or structural anomalies were noted with the oil line or fitting. The engine had been recently overhauled, and the two mechanics who performed the overhaul stated it was very possible that they did not properly torque the oil line fitting. Following the accident, the overhaul facility implemented a requirement to torque seal applicable components to help ensure compliance with torque specifications.

Factual narrative

On October 20, 2020, about 2020 central daylight time, a Piper PA-28-140 airplane, N5932U, was substantially damaged when it was involved in an accident near Buda, Texas. The flight instructor and student pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 flight. The flight instructor stated that while in cruise flight during the night training flight, the engine started to lose rpm, vibrate, and subsequently lost all power. During the descent, the flight instructor and student coordinated to select the closest runway and attempted to land at a private airport. After noticing the airplane was not able to the glide to the runway, the flight instructor conducted a forced landing onto rough terrain, which damaged the right-wing spar. A postaccident examination revealed significant thermal damage to the engine, a nearly empty oil reservoir, and a disconnected oil line fitting to the oil pressure indicator. Oil residue was trailing on the underside of the fuselage and the bottom of the elevator surface. Examination of the oil line fitting revealed no material or structural anomalies with the oil line or fitting. The accident was the airplane’s second flight following an engine overhaul due to a propeller strike. The two mechanics who conducted the overhaul stated that since both were involved and no procedure was in place to “verify all lines” were torqued properly, it was very possible the oil line fitting may have been missed. Following the accident, the overhaul facility implemented a requirement to torque seal applicable components during an overhaul to ensure compliance with torque specifications. This best practice is described in NTSB Safety Alert SA-056, “Take Time to Torque” (available at https://www.ntsb.gov/Advocacy/safety-alerts/Documents/SA-056.pdf) as well as in a maintenance article highlighting the importance of proper torque protocols that was published in the July 2018 FAA Safety Brief (located in the docket for this investigation).

Aircraft

Registration
N5932U
Reported as
Piper PA28 (140)
Category
Airplane
Serial number
28-7125143
Built
1971
Airframe hours
7,960
Engine
Lycoming O-320, 160 hp, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 21, 2020 · 3 hours before
Departed
1T8 · Bulverde, TX
Destination
KAUS · Austin, TX
Flight plan
VFR
Equipment
ADS-B, Handheld GPS, Stall warning system

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
51
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
December 12, 2019
Seat
Right
Restraint
Lap only
Flight hours
775 total · 491 in this make and model · 687 as pilot in command · 190 in the last 90 days · 54 in the last 30 days · 1 in the last 24 hours
Role
Student pilot
Age
39
Injuries
None
Certificate
Student
Medical
Class 3, Without waivers/limitations
Seat
Left
Restraint
Lap only
Flight hours
54 total · 54 in this make and model · 1 as pilot in command · 23 in the last 90 days · 8 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
140° at 7 knots
Visibility
10 statute miles
Temperature
82 °F, dew point 66 °F
Altimeter
29.93 inHg
Observed at
KAUS, 16 nm away
METAR
KAUS 210053Z 14007KT 10SM FEW060 FEW150 28/19 A2993 RMK AO2 SLP125 T02780189

Docket · 6

The files NTSB released with the investigation on April 28, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 33.8 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.

Other investigations on N5932U · 1

Matched to the same aircraft by N-number and date.