CEN21LA175

NTSB accident investigation · Piper PA-28-140 · Augusta, KS · April 1, 2021

Accident · No injuriesClass 3 · LimitedFinal report
Date
April 1, 2021, 16:00 local (21:00 UTC)
Place
Augusta, KS
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N7274FPiper PA-28-140
Defining event
Approach-IFR final approach: Loss of engine power (partial)
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
20210401003349A
Case key
102857

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

Inadequate maintenance at the time the carburetor was replaced, which resulted in the improperly installed throttle cable and a partial loss of engine power. Contributing to the accident was an inadequate annual inspection that failed to detect the improper throttle cable installation.

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 fuel and control: fuel control/carburetorAircraft › Aircraft power plant · Incorrect service/maintenancePiper PA-28-140: 7 casesAll aircraft: 195 casesProbable cause
Maintenance: replacementPersonnel issues › Task performance · Maintenance personnelPiper PA-28-140: 2 casesAll aircraft: 70 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelPiper PA-28-140: 5 casesAll aircraft: 167 cases
Engine fuel and control: fuel control/carburetorAircraft › Aircraft power plant · Inadequate inspectionPiper PA-28-140: 7 casesAll aircraft: 195 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 performing a practice instrument approach with a safety pilot onboard when the accident occurred. Upon crossing the final approach fix inbound, he reduced engine power to initiate a descent. Shortly afterward, he attempted to increase engine power slightly; however, there was no response. He subsequently applied full throttle without any corresponding increase in engine power. Attempts to restore adequate engine power were not successful and the pilot executed a forced landing to a field during which the airplane sustained substantial damage. A postaccident examination revealed that the throttle cable had become disconnected from the carburetor throttle arm. The attachment hardware was not located. The airplane parts catalog specified that a castellated nut and cotter pin be used to secure the throttle cable rod end bearing to the carburetor. No other anomalies with respect to the engine, carburetor, or throttle cable were observed. The airplane maintenance records indicated that the carburetor was replaced about 23 flight hours before the accident. An annual inspection was completed about 11 flight hours before the accident. Based on the available information, it is likely that the throttle cable was not properly secured to the carburetor throttle arm when the carburetor was replaced; specifically, the cotter pin was not installed. The missing cotter pin was not detected during the annual inspection. The engine power available at the time the cable became disconnected was not sufficient to maintain altitude, resulting in a descent and forced landing.

Factual narrative

On April 1, 2021, about 1600 central daylight time, a Piper PA-28-140, N7274F, was substantially damaged when it was involved in an accident near Augusta, Kansas. The pilot and safety pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he was performing a practice VOR/DME-A instrument approach into Augusta Municipal Airport (3AU) with a safety pilot onboard. Shortly after passing the final approach fix inbound, he reduced engine power. He then attempted to increase engine power slightly; however, there was no response. He subsequently increased to full throttle without any corresponding increase in engine power. The pilot’s efforts to restore engine power were not successful and he executed a forced landing to a field. The safety pilot reported that the pilot reduced engine power and initiated a descent upon crossing the final approach fix inbound. About 30 seconds later, the pilot informed him that the engine was not responding. The safety pilot recalled that the engine tachometer was at an idle rpm indication. He noted that there was about 3 hours fuel onboard at the time of the accident. A postaccident examination was conducted by a Federal Aviation Administration inspector. The right wing struck a trailer and a fence post during the landing rollout and separated from the fuselage. The airplane came to rest adjacent to an outbuilding. The left wing remained attached to the fuselage. The fuselage, both wings, engine mount and propeller were damaged. An undetermined amount of fuel remained in the left fuel tank, the right fuel tank had been compromised, and a strong fuel odor was present at the accident site. The examination revealed that the throttle cable rod end bearing was not connected to the carburetor throttle arm. The attachment hardware was not located. The mixture cable remained attached to the carburetor. Both the throttle and mixture control cables were continuous from the cockpit controls to the engine compartment. The carburetor appeared undamaged and was securely mounted to the engine. The engine assembly appeared intact. The airplane maintenance records indicated that the carburetor had been replaced on January 17, 2021, at a recording tachometer time of 8,244 hours. An annual inspection was completed on March 4, 2021, at 8,256 hours. The tachometer indicated 8,267 hours at the time of the examination. Review of the airplane parts catalog noted that the throttle cable was to be secured to the carburetor throttle arm rod end bearing using a hex-head bolt with a drilled shank (AN3-7), a castellated nut (AN310-3), and a cotter pin (MS24665-132).

Aircraft

Registration
N7274F
Reported as
Piper PA-28-140 (NO SERIES)
Category
Airplane
Serial number
28-7725088
Built
1976
Airframe hours
8,838.3
Engine
Lycoming O-320-E2A, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Pray Aviation
Registered owner
Pray Aviation
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
Annual · March 4, 2021 · 10.8 hours before
Departed
BKN · Blackwell, OK
Destination
Same as departure
Airport
3AU · Augusta Muni
Equipment
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
Pilot
Age
38
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
February 20, 2019
Seat
Left
Restraint
3-point
Flight hours
156 total · 4 in this make and model
Role
Other flight crew
Age
19
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
January 22, 2021
Seat
Right
Restraint
3-point

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 8 knots, gusting 15
Visibility
10 statute miles
Lowest ceiling
None
Temperature
59 °F, dew point 21 °F
Altimeter
30.42 inHg
Observed at
3AU, 1.5 nm away

Docket · 9

The files NTSB released with the investigation on July 27, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 233 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.