CHI95LA104

NTSB accident investigation · Piper PA-28-181 · Ann Arbor, MI · March 19, 1995

Accident · Minor injuriesLimited investigationFinal report
Date
March 19, 1995, 15:02 local (20:02 UTC)
Place
Ann Arbor, MI
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Emergency descent
Aircraft
N4385MPiper PA-28-181
Weather
Visual (VMC) · Day
Status
Completed · report August 23, 1995
Report
Approved by Office Director
FAA report
19950319004329A
Case key
9853

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

the failure of the mechanic to close the drain valve after changing oil, resulting in complete loss of engine oil. A factor was the soft terrain, which resulted in the nose wheel digging in and the airplane nosing over.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - mech failure/malfEmergency descent/landing
Lubricating system,oil quickdrain/drain plug - openFactor
Maintenance - improperOther maintenance personnelCause
Fluid,oil - loss,total
Powerplant - seized
Forced landingEmergency descent/landing
Nose gear collapsedEmergency landing
Terrain condition - softFactor
Nose overEmergency landing

Analysis

Ten minutes after takeoff the oil pressure dropped to zero and the pilot attempted to return to the airport. The engine began to seize, the pilot pulled mixture to idle-cutoff, and performed a forced landing in a field. The nose wheel dug into the soft ground, and the airplane nosed over. The oil drain valve was found in the open position, with fresh oil on the airplane. The mechanic stated he had placed a paper plug in the drain to prevent drips, and failed to close the valve.

Factual narrative

On March 19, 1995, at 1502 eastern standard time (EST), a Piper PA-28-181, N4385M, operated as a rental airplane by Ann Arbor Flyers, Incorporated, of Ann Arbor, Michigan, impacted in a level field two miles northwest of Ann Arbor Municipal Airport (ARB), and was substantially damaged. The private pilot was uninjured, and the passenger received minor injuries. No fire occurred. Visual meteorological conditions existed at the time of the accident, no flight plan was filed. The flight originated at 1445 EST, as a 14 CFR Part 91 local pleasure flight.

The pilot reported that during her preflight, the engine was being recowled after a scheduled oil change. She reported that during her engine runup, all indications were normal, but during the initial climb, ten minutes after takeoff, oil pressure dropped to zero (0). During her precautionary return to ARB, the engine began to run rough, she selected an off airport field to land in, and secured the engine. During the forced landing in an uncultivated field, the nose wheel broke off and the airplane flipped over.

The mechanic who had changed the oil stated "When draining was complete an external drain tube was removed without closing the valve. Then a paper plug was inserted in the valve to avoid drips inside the cowl from the 'closed' valve. This plug prevented what should have been obvious flow thru onto the floor at the time of refill."

Post crash inspection revealed the engine oil quick drain in the open position, and the bottom of the airplane covered with engine oil.

Aircraft

Registration
N4385M
Reported as
Piper PA-28-181
Category
Airplane
Serial number
28-8590025
Engine
Lycoming O-360, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Ann Arbor Flyers, Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 18, 1995 · 0 hours before
Departed
ARB · MI

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
32
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
399 total · 271 in this make and model · 332 as pilot in command · 5 in the last 90 days · 2 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 13 knots
Visibility
10 statute miles
Lowest ceiling
6,500 ft broken
Temperature
54 °F, dew point 36 °F
Altimeter
29.00 inHg
Observed at
ARB, 2 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.