ERA09LA163

NTSB accident investigation · Piper PA28 · Pittstown, NJ · February 11, 2009

Accident · Serious injuriesLimited investigationFinal report
Date
February 11, 2009, 16:42 local (21:42 UTC)
Place
Pittstown, NJ
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N55854Piper PA28
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report May 12, 2009
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Lycoming, Piper Aircraft Inc
FAA report
20090211000929A
Case key
73346

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

A loss of engine power due to the improper tightening of a fuel hose B-nut by maintenance personnel during engine installation.

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.

Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelPiper PA-28-180: 1 caseAll aircraft: 167 casesProbable cause
Terrain: rough terrainEnvironmental issues › Physical environment · Contributed to outcomePiper PA-28-180: 2 casesAll aircraft: 442 cases
Fuel systemAircraft › Aircraft systems · Incorrect service/maintenancePiper PA-28-180: 2 casesAll aircraft: 181 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 pilot-rated passenger stated that he departed from runway 25, flying the airplane from the left front seat, with the boost pump on. During the initial takeoff climb, the fuel pressure gauge indicated zero. The engine sputtered, lost power, and the pilot-rated passenger selected a forced landing area. The engine then started, and the pilot started a turn back to the airport and the engine lost power again. The airplane collided with trees and the ground during a forced landing to a residential area. During examination and removal of the fuel system hoses to the carburetor, a loose fuel hose B-nut was found. Review of the airplane logbooks revealed the airplane engine was overhauled about 5 years prior to the accident, and put into storage until it was sold about 1 month prior to the accident. An annual inspection was conducted at that time, and the airplane had flown 4.79 hours since the last overhaul and annual inspection. According to data from the engine manufacturer, the required torque for the B-nut is 35 in/lbs. A follow-up fuel line leak test was performed, with the fuel supply selector and electric boost pump were turned on. The fuel pressure gauge indicated 4.5 ponds-per-square-inch (PSI). The fuel line B-nut was loosened and the fuel pressure dropped 1.5 PSI with a recording of 3 PSI for 5 seconds. Subsequently, fuel was observed leaking from the loosened B-nut.

Factual narrative

On February 11, 2009, at 1642 eastern standard time, a Piper PA-28-180, N55854, registered to KS Air Corporation, operating as a 14 Code of Federal Regulations Part 91 personal flight, lost total engine power during the initial climb from Sky Manor Airport (N40), Pittstown, New Jersey. The airplane collided with trees and the ground, receiving structural damage to the airframe during the forced landing to a residential area. Visual meteorological conditions prevailed and no flight plan was filed. The certificated commercial pilot received serious injuries. The pilot-rated passenger received minor injuries. The flight originated at 1640. The pilot-rated passenger stated no anomalies were noted during the preflight inspection or engine run-up. He departed from runway 25 flying the airplane from the left front seat with the electric boost pump on. During initial takeoff climb, the fuel pressure gauge indicated zero. The engine sputtered, quit, and the pilot-rated passenger selected a forced landing area. The engine then started, and he started a shallow turn back to the airport. The engine quit again, he leveled the airplane and it collided with trees and the ground. A postcrash fire ensued in the engine compartment, and a resident extinguished the fire. Review of the aircraft logbooks revealed the airplane was equipped with a Lycoming O-360-A4A engine. The engine was field overhauled at tachometer 5,502 hours on May 5, 2004 and put into preserved storage until it was sold. The last annual inspection on the airplane was completed on January 9, 2009, at 5,502 tachometer hours. The tachometer at the crash site read 5,506.79 hours. The airplane had flown 4.79 hours since the last overhaul and annual inspection. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed the left wing was separated from the airplane, and the empennage received structural damage. Evidence of a small fire was observed near the air box and upper right rear section of the engine, near the magneto and magneto harness. Examination of the airframe and flight controls revealed no evidence of a precrash mechanical failure or malfunction. The engine assembly to the airframe structure and was compressed against the lower aircraft firewall. The structural mounts were bent downward and the exhaust system was partially crushed. A lighted borescope was used to examine the internal top end components. No preimpact anomalies were revealed. The spark plugs were removed and exhibited clean, light tan color combustion deposits. The crankshaft was rotated by hand and continuity of the crankshaft, camshaft, valve train, and accessory drives was established. Compression was present on all cylinders. Examination of the lubrication system, induction system, carburetor, ignition system, magnetos, harness leads, and spark plugs revealed no anomalies. Fuel was present within all of the fuel lines and components forward of the gascolator on the firewall. Duringremoval of the fuel system hoses to the carburetor, a loose fuel hose B-nut was found. No impact or fire damage was noted in the area. The loose fuel hose B-nut was found to be one-half turn counterclockwise off from the torqued position. It was located at the fitting from the fuel line that runs from the engine driven fuel pump to the carburetor. All of the other fuel hose connections in the engine compartment were found tight and secure when examined or removed. According to Lycoming Torque Value Recommendations (SSP1776), Pg. 2-23. Table IV, FLEXABLE HOSE OR TUBE FITTINGS: The required torque for a (-6), /3/8 Size is 35 in/lbs. Representatives from the airplane manufacturer conducted a follow up fuel line leak test on another Piper PA28-181, on February 23, 2009. The model of airplane used for the test had its T-fitting located at the carburetor. The fuel supply selector and electric boost pump were turned on. The fuel pressure gauge indicated 4.5 pounds-per-square-inch (PSI). The fuel line B-nut located at the exit side of the engine driven fuel pump was loosened. The fuel pressure then dropped 1.5 PSI with a recording of 3 PSI for 5 seconds. Subsequently, fuel was observed leaking from the loosened B-nut.

Aircraft

Registration
N55854
Reported as
Piper PA28 (180)
Category
Airplane
Serial number
28-730-5485
Engine
Lycoming O360-A3A, 180 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Departed
N40 · Pittstown, NJ
Destination
N40 · Pittstown, NJ

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
28
Injuries
Serious
Certificates
Private, Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
June 13, 2008
Seat
Right
Flight hours
565 total

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 46 °F
Altimeter
29.70 inHg
Observed at
DYL, 15 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.

Other investigations on N55854 · 1

Matched to the same aircraft by N-number and date.