# NTSB CEN21LA175: Piper PA-28-140, N7274F, Augusta, KS, April 1, 2021 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: April 1, 2021, 16:00 local (21:00 UTC) - Place: Augusta, KS - Coordinates: 37.65588, -97.0599 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.6559&lon=-97.0599&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR final approach: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA -- Flight Standards - NTSB case key (mKey): 102857 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21LA175 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102857/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102857 - Page: https://openairdocs.org/ntsb/CEN21LA175 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine fuel and control: fuel control/carburetor](https://openairdocs.org/ntsb-findings/01057322): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-28-140, 7 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md?model=7102802), [All aircraft, 195 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md) - [Maintenance: replacement](https://openairdocs.org/ntsb-findings/02062020): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28-140, 2 cases](https://openairdocs.org/ntsb-findings/02062020/cases.md?model=7102802), [All aircraft, 70 cases](https://openairdocs.org/ntsb-findings/02062020/cases.md) - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel; cases with it: [Piper PA-28-140, 5 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=7102802), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md) - [Engine fuel and control: fuel control/carburetor](https://openairdocs.org/ntsb-findings/01057322): Aircraft › Aircraft power plant · Inadequate inspection (probable cause); cases with it: [Piper PA-28-140, 7 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md?model=7102802), [All aircraft, 195 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR final approach: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Piper PA-28-140, 47 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7102802), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-140, 56 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102802), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-140, 137 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102802), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N7274F-2022-07-30), registration cancelled 2022-07-30, S/N 28-7725088, built 1976 (OpenAirDocs) - Reported make and model: PIPER PA-28-140 (NO SERIES) - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7725088 - Year built: 1976 - Airframe hours: 8838.3 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 38; injuries: minor; 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 - Other flight crew; age 19; injuries: none; 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 ## 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 20210401003349A](https://openairdocs.org/incident/20210401003349A), Apr 1, 2021: Piper PA-28-140, Augusta, KS, Destroyed. During the approach to Augusta municipal airport upon reaching the final approach fix for the vor/dme-a approach at 3000 ft. MSL the pilot reduced power. When… ## Docket (9 files) The files NTSB released with the investigation on July 27, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102857. 233 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 34.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12243015&FileExtension=pdf&FileName=Accident%20Report%20--%20CEN21LA175_redacted-Rel.pdf - Pilot statement (item 2, PDF, 1 page, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12244450&FileExtension=pdf&FileName=Pilot%20Stmt%20--%20PIC_Trenum(PrayAviation)-Rel.pdf - Safety pilot statement (item 3, PDF, 1 page, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12244081&FileExtension=pdf&FileName=Pilot%20Stmt%20--%20SIC_Frisch(PrayAviation)-Rel.pdf - Accident photos (item 4, PDF, 4 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12243986&FileExtension=pdf&FileName=Accident%20Photos%20--%20CEN21LA175-Rel.pdf - Airplane examination summary (item 5, PDF, 2 pages, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12250699&FileExtension=pdf&FileName=Examination%20Summary%20--%20CEN21LA175-Rel.pdf - Maintenance records -- airframe (item 6, PDF, 9 pages, 70.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12244330&FileExtension=pdf&FileName=Maintenance%20Records%20--%20Airframe_N7274F_redacted-Rel.pdf - Maintenance records -- engine (item 7, PDF, 11 pages, 125 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12244256&FileExtension=pdf&FileName=Maintenance%20Records%20--%20Engine_N7274F_redacted-Rel.pdf - Airplane parts catalog (excerpt) -- engine controls installation (item 8, PDF, 7 pages, 263 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12250709&FileExtension=pdf&FileName=Parts%20Catalog%20(Excerpt)%20--%20Engine%20Controls%20Installation-Rel.pdf - FAA terminal procedure -- vor/dme a (item 9, PDF, 1 page, 191 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12244366&FileExtension=pdf&FileName=FAA%20Terminal%20Proc%20--%20VOR_DME_A%20(3AU)-Rel.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.