CEN25LA053

NTSB accident investigation · Piper PA-28R-200 · Boscobel, WI · December 2, 2024

Accident · No injuriesClass 3 · LimitedFinal report
Date
December 1, 2024, 18:21 local (Dec 2, 2024, 00:21 UTC)
Place
Boscobel, WI
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N41997Piper PA-28R-200
Defining event
Enroute-cruise: Structural icing
Weather
Visual (VMC) · Night/dark
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Lycoming Engines, FAA
FAA report
20241201022289A
Case key
195571

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 ice obstruction of the engine oil breather tube and alternate air outlet, which resulted in a failure of the crankcase oil seal and loss of engine oil. Contributing to the accident was the incorrect engine oil breather tube installed in the airplane by maintenance personnel.

Findings · 3

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.

Temp/humidity/pressure: conducive to structural icingEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentPiper PA-28R-200: 2 casesAll aircraft: 103 casesProbable cause
Eng oil sys (airframe furnish): pressureAircraft › Aircraft power plant · MalfunctionPiper PA-28R-200: 1 caseAll aircraft: 6 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelPiper PA-28R-200: 4 casesAll aircraft: 371 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 cruise on the return leg of a night cross-country instructional flight at 9,000 ft mean sea level (msl), the flight instructor and student pilot noticed an odor in the cockpit. The flight instructor then noticed an opaque windscreen and immediately thought they had encountered icing conditions. The flight instructor contacted air traffic control (ATC) and requested a lower altitude. Using a flashlight, the flight instructor illuminated the windscreen and noticed a “brown river” completely obscuring their forward visibility. The cockpit engine oil pressure gauge indicated little to no oil pressure. The flight instructor declared an emergency with ATC and assumed control of the airplane from the pilot receiving instruction. The flight instructor located the nearest airport to attempt a forced landing. However, due to restricted visibility due to the oil-covered windscreen, the airplane landed hard adjacent to the runway, bounced, and then came to rest upright on the ground. The airplane sustained substantial damage to the right horizontal stabilator, and the airframe contained engine oil on the top engine cowling, windscreen, and empennage. During recovery of the airplane, recovery personnel noted that ice obstructed the engine oil breather tube and the alternate air outlet. The obstructed breather tube created increased crankcase pressure and caused the extrusion of the solid-ring crankshaft oil seal from the crankcase and subsequent loss of engine oil. Airplane records showed that the oil engine breather tube was replaced about 18 years before the accident. The design, fabrication, and installation of the accident airplane’s oil breather tube did not comply with the airplane manufacturer’s original design criteria. Specifically, the oil breather tube protruded about 3” outside the engine cowling when it should only extend 0.5”. The additional length of oil breather tube outside of the engine cowling would be more susceptible to ice accretion during flight. Additionally, the replaced oil breather tube was not fabricated with alternate air outlets that were positioned within the engine compartment, which would have provided an unobstructed vent after the primary outlet became contaminated with ice during the flight.

Factual narrative

On December 1, 2024, at 1821 central standard time, a Piper PA-28R-200 airplane, N41997, sustained substantial damage when it was involved in an accident near Boscobel, Wisconsin. The flight instructor and pilot receiving instruction were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the flight instructor, they were established in cruise flight on the return leg of a night cross-country instructional flight at 9,000 ft msl, when they noticed an odor in the cockpit. The flight instructor noted no additional issues in the cockpit, and adjusted the cabin heat control, after which the odor diminished. The flight instructor then noticed an opaque windscreen and immediately thought they had encountered icing conditions. The flight instructor contacted ATC and requested a lower altitude. Using a flashlight, the flight instructor illuminated the windscreen and noticed a “brown river” completely obscuring their forward visibility. The cockpit engine oil pressure gauge indicated little to no oil pressure. The flight instructor declared an emergency with ATC and took over control of the airplane from the pilot receiving instruction. The flight instructor located the nearest airport to attempt a forced landing. However, due to restricted visibility due to the oil-covered windscreen, the airplane landed hard adjacent to the runway, bounced, and then came to rest upright on the ground. The airplane sustained substantial damage to the right horizontal stabilator, and the airframe contained engine oil on the top engine cowling, windscreen, and empennage. During recovery of the airplane, recovery personnel noted that the engine oil breather tube and alternate air outlet was obstructed by ice that accumulated during the flight (see Figure 1). Figure 1. Ice-obstructed engine oil breather tube and alternate air outlet. (Source: Myers Aviation - Recovery Company) Additional postaccident examination of the engine revealed that the solid-ring crankshaft oil seal was extruded from the crankcase (see Figure 2). Figure 2. Extruded crankshaft oil seal. According to the airplane manufacturer, Piper Aircraft, Inc., the engine oil breather tube should contain two secondary alternate air outlets that are located within the engine cowling area of the airframe. Additionally, the breather tube primary outlet should not extend beyond 0.5” outside of the engine cowling. The accident airplane’s engine oil breather tube, which was not a Piper Aircraft, Inc. part, contained one alternate air outlet that was fabricated about 1.5” from the end of the breather tube. The end of the breather tube extended about 3” outside of the engine cowling (see Figure 3). Figure 3. Removed breather tube with alternate air outlet and location of engine cowling. A review of the maintenance records revealed that the engine oil breather tube was replaced (part number unknown) on December 18, 2006. No subsequent maintenanceentries were noted that referenced any maintenance of the breather tube.

Aircraft

Registration
N41997
Reported as
Piper PA-28R-200
Category
Airplane
Serial number
28R-7435235
Built
1974
Airframe hours
4,972
Engine
Lycoming IO-360-C1C, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 26, 2024
Departed
FRM · Fairmont, MN
Destination
3CK · Lake in the Hills, IL
Flight plan
IFR
Airport
OVS · Boscobel, runway 07/25, 5,000 × 75 ft, asphalt
Equipment
Stall warning system, Auto-pilot, ADS-B

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
42
Injuries
None
Certificates
Airline transport, Commercial, Flight instructor
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
June 29, 2024
Seat
Right
Restraint
3-point
Flight hours
12,000 total · 100 in this make and model · 4,300 as pilot in command · 200 in the last 90 days · 60 in the last 30 days · 4 in the last 24 hours
Role
Student pilot
Age
18
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Unknown, Unknown
Last flight review
October 1, 2024
Seat
Left
Restraint
3-point

Weather

Conditions
Visual (VMC) · Night/dark
Wind
20° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
14 °F, dew point 7 °F
Altimeter
30.34 inHg
Observed at
KOVS
METAR
KOVS 020053Z AUTO 02004KT 10SM CLR M10/M14 A3034 RMK AO2 SLP292 T11001139 $

Docket · 7

The files NTSB released with the investigation on April 1, 2025, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.8 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.