CEN24LA286

NTSB accident investigation · Piper PA46 · Radisson, WI · July 28, 2024

Accident · No injuriesClass 3 · LimitedFinal report
Date
July 28, 2024, 11:30 local (16:30 UTC)
Place
Radisson, WI · Estimated: Open field near the intersection of Brisko Road and Weirgor Road
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4646GPiper PA46
Defining event
Enroute-descent: 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 Minneapolis FSDO, Continental Aerospace Technologies
FAA report
20240728011999A
Case key
194788

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

The non-certificated mechanic’s failure to properly tighten and torque the fuel system pressure test port cap, which resulted in a total loss of engine power, and a subsequent forced landing.

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.

Engine (reciprocating)Aircraft › Aircraft power plant · FailurePiper PA-46-310P: 1 caseAll aircraft: 497 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelPiper PA-46-310P: 1 caseAll aircraft: 320 casesProbable cause
Engine fuel and controlAircraft › Aircraft power plant · Incorrect service/maintenancePiper PA-46-310P: 1 caseAll aircraft: 49 casesProbable cause
Action: forgotten action/omissionPersonnel issues › Action/decision · Maintenance personnelPiper PA-46-310P: 2 casesAll aircraft: 440 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 engine sustained a total loss of power when nearing the destination airport during a cross-country flight. The pilot performed a forced landing to a rural grass field and the airplane landed hard, coming to rest upright. The pilot was able to egress from the airplane without further incident. The airplane sustained substantial damage to the fuselage and the empennage. An on-site examination of the engine found that a cap was missing from the fuel pressure test port near the front top area of the engine. The test port is where a gauge would connect during maintenance work to test the fuel pressure. The test port and the aluminum housing that the port connects to both had blue staining. The exposed threading that the cap screws onto was found intact and the missing cap was not located. A review of the engine monitor performance data showed performance consistent with a total loss of engine power. The fuel flow rate had increased up to the maximum reading, about 80 gallons per hour, at the time the total loss of engine power occurred. A review of the most recent airplane maintenance records showed than an annual inspection was performed on the airframe, engine, and propeller about six weeks before the accident. The records reflected work completed on the fuel injection system, including the installation of new fuel injectors. According to the engine manufacturer, a fuel system operational check is required if fuel injectors are replaced. Test equipment is connected to the fuel pressure test port and a test is performed. Once the test work is completed, a cap is required to be tightened and torqued on the test port. The individual who performed the most recent annual inspections on the airplane did not hold an airframe and powerplant certificate, nor did he hold inspection authorization. The non-certificated mechanic signed off the annual inspections and returned the airplane to service using the airframe and powerplant mechanic certificate number of his deceased father, who held inspection authorization. The test port had blue staining present, and the exposed threading was found intact. The aluminum housing that the port connects to also had blue staining present. The blue staining was likely from a 100 low-lead fuel leak while in-flight. It is likely the loss of fuel and fuel system pressure caused a total loss of engine power. Based on the available evidence, it is likely that the non-certificated mechanic forgot to properly tighten and torque the fuel pressure test port cap, which resulted in a total loss of engine power. The non-certificated mechanic fraudulently represented himself as a certificated mechanic with inspection authorization and the appropriate knowledge, training, and experience by signing off the annual inspections and returning the airplane to service.

Factual narrative

On July 28, 2024, about 1130 central daylight time, a Piper PA-46-310P airplane, N4646G, sustained substantial damage when it was involved in an accident near Radisson, Wisconsin. The commercial pilot sustained no injury. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal cross-country flight. The airplane departed from the Lake in the Hills Airport (3CK), Lake in the Hills, Illinois, about 0930. Before departure from 3CK, the pilot reported the airplane had 85 gallons of 100 low-lead fuel onboard. The airplane, operating on an instrument flight rules flight plan, traveled to the northwest, toward the destination of the Sawyer County Airport (HYR), Hayward, Wisconsin. About 25 miles southeast of HYR, the reciprocating engine sustained a total loss of power, and the pilot declared an emergency to air traffic control. The pilot performed a forced landing to a rural grass field containing trees. The airplane came to rest upright, and the pilot was able to egress from the airplane without further incident. The airplane sustained substantial damage to the fuselage and the empennage. An on-site examination of the engine by the FAA found that a cap was missing from the fuel pressure test port (a 90° brass elbow port) near the front top of the engine. The test port had blue staining present, and the exposed threading was found intact. The test port is where a gauge would connect during maintenance work to test the fuel pressure. The aluminum housing that the port connects to also had blue staining present. The missing cap was not recovered. A J.P. Instruments Engine Data Monitor 900 unit was removed from the airframe and the engine performance data was downloaded and reviewed. The engine performance data showed that the fuel flow rate had increased up to the maximum reading, about 80 gallons per hour, at the time the total loss of engine power occurred. Per the engine manufacturer the fuel system is a closed system. With the test port cap off, it becomes an open system, as shown with the blue staining in the two areas. As fuel is lost, fuel pressure is lost, and the engine then quits. A review of the most recent airplane maintenance records showed than an annual inspection was performed on the airframe, engine, and propeller on June 14, 2024, about 6 weeks before the accident. The records reflected work completed on the fuel injection system, including the installation of new fuel injectors. The entries for the annual inspections stated that the airplane was found in to be in an airworthy condition and the airplane was returned to service. According to the Continental Motors Standard Practice Maintenance Manual M-0, a fuel system operational check is required if fuel injectors are replaced. Test equipment is connected to the fuel pressure test port and a test is performed. Once the test work is completed, a cap (Continental Motors part number 639494) is required to be tightened and torqued on the test port. ContinentalMotors Standard Practice Maintenance Manual M-0 includes a warning that states: Failure to connect and torque fuel system fittings to the proper specification will result in a fuel leak and potential fire hazard. The individual who performed the most recent annual inspections on the airplane did not hold an airframe and powerplant certificate, nor did he hold inspection authorization. The non-certificated mechanic signed off the annual inspections and returned the airplane to service using the airframe and powerplant mechanic certificate number of his deceased father, who held inspection authorization. The father passed away on June 25, 2007.

Aircraft

Registration
N4646G
Reported as
Piper PA46 (310P)
Category
Airplane
Serial number
46-8508101
Built
1985
Airframe hours
5,194.6
Engine
Continental Motors TSIO-550C, 350 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Piper Malibu N4646g LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 15, 2024 · 20 hours before
Departed
3CK · Lake in the Hills, IL
Destination
HYR · Hayward, WI
Flight plan
IFR
Equipment
Stall warning system, Onboard weather, Electronic primary flight display, ADS-B, Auto-pilot, Data recorder, Electronic flight bag or handheld device

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
58
Injuries
None
Certificates
Private, Commercial
Airplane ratings
Single-engine land, Single-engine sea, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
June 18, 2024
Seat
Left
Restraint
3-point
Flight hours
2,400 total · 300 in this make and model · 23 in the last 90 days · 18 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 11 knots, gusting 14
Temperature
77 °F, dew point 68 °F
Altimeter
29.94 inHg
Observed at
KRCX, 18 nm away
METAR
KRCX 281615Z AUTO 17011G14KT SCT018 25/20 A2994 RMK AO2 T02520199 PWINO

Docket · 12

The files NTSB released with the investigation on April 2, 2025, on NTSB’s docket system: statements, records, photos and specialists’ reports. 43.2 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.