# NTSB CEN25LA053: Piper PA-28R-200, N41997, Boscobel, WI, December 2, 2024 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: December 1, 2024, 18:21 local (Dec 2, 2024, 00:21 UTC) - Place: Boscobel, WI - Coordinates: 43.15947, -90.678168 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.1595&lon=-90.6782&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Structural icing](https://openairdocs.org/ntsb-events/210) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Lycoming Engines, FAA - NTSB case key (mKey): 195571 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN25LA053 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/195571/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=195571 - Page: https://openairdocs.org/ntsb/CEN25LA053 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Temp/humidity/pressure: conducive to structural icing](https://openairdocs.org/ntsb-findings/03031025): Environmental issues › Conditions/weather/phenomena · Effect on equipment (probable cause); cases with it: [Piper PA-28R-200, 2 cases](https://openairdocs.org/ntsb-findings/03031025/cases.md?model=7102811), [All aircraft, 103 cases](https://openairdocs.org/ntsb-findings/03031025/cases.md) - [Eng oil sys (airframe furnish): pressure](https://openairdocs.org/ntsb-findings/01057931): Aircraft › Aircraft power plant · Malfunction (probable cause); cases with it: [Piper PA-28R-200, 1 case](https://openairdocs.org/ntsb-findings/01057931/cases.md?model=7102811), [All aircraft, 6 cases](https://openairdocs.org/ntsb-findings/01057931/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28R-200, 4 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=7102811), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Structural icing](https://openairdocs.org/ntsb-events/210) (defining event); cases with it: [Piper PA-28R-200, 1 case](https://openairdocs.org/ntsb-events/210/sequence.md?model=7102811), [All aircraft, 102 cases](https://openairdocs.org/ntsb-events/210/sequence.md) - [Enroute-cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340); cases with it: [Piper PA-28R-200, 6 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=7102811), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28R-200, 45 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102811), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N41997), registered now, S/N 28R-7435235, built 1974 (OpenAirDocs) - Reported make and model: PIPER PA-28R-200 - Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7435235 - Year built: 1974 - Airframe hours: 4972 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 42; injuries: none; 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 - Student pilot; age 18; injuries: none; 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 $ ## 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 20241201022289A](https://openairdocs.org/incident/20241201022289A), Dec 1, 2024: Piper PA28R-200, Boscobel, WI, Substantial damage. On 01 dec 2024, 13:45 CST (central standard time) Piper PA28R-200 1975 arrow ii, [privacy data omitted] operating as a planned 14 CFR part 91 IFR training… ## Docket (7 files) The files NTSB released with the investigation on April 1, 2025, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=195571. 8.8 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 10 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18219455&FileExtension=pdf&FileName=6120_1_Form_Redacted-Rel.pdf - Aircraft examination summary (item 2, PDF, 12 pages, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18221765&FileExtension=pdf&FileName=Aircraft%20Examination%20Summary%202-Rel.pdf - Memorandum of record - recovery company (item 3, PDF, 1 page, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18222909&FileExtension=pdf&FileName=Memo%20of%20Record%20-%20Myers%20Aviation-Rel.pdf - Maintenance entry - engine oil breather tube installation (item 4, PDF, 1 page, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18220795&FileExtension=pdf&FileName=Breather%20Tube%20Replacement12_18_06_Redacted-Rel.pdf - Investigation photographs (item 5, PDF, 5 pages, 852 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18219688&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Statement of party representatives to NTSB investigation (item 6, PDF, 1 page, 294 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18219083&FileExtension=pdf&FileName=Certification%20of%20Party%20Representative%20-%20Lycoming_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 7, PDF, 2 pages, 939 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18221737&FileExtension=pdf&FileName=NTSB%20Wreckage%20Release%20N41997signed_Redacted-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.