# NTSB ERA09LA163: Piper PA28, N55854, Pittstown, NJ, February 11, 2009 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: February 11, 2009, 16:42 local (21:42 UTC) - Place: Pittstown, NJ - Coordinates: 40.566387, -74.978614 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.5664&lon=-74.9786&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed, report May 12, 2009 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Lycoming, Piper Aircraft Inc - NTSB case key (mKey): 73346 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09LA163 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73346/pdf - Page: https://openairdocs.org/ntsb/ERA09LA163 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28-180, 1 case](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=7102808), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md) - [Terrain: rough terrain](https://openairdocs.org/ntsb-findings/03021015): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-180, 2 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md?model=7102808), [All aircraft, 442 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md) - [Fuel system](https://openairdocs.org/ntsb-findings/01022800): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-28-180, 2 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md?model=7102808), [All aircraft, 181 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Piper PA-28-180, 3 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=7102808), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-28-180, 37 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102808), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-180, 40 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102808), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## 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](https://openairdocs.org/deregistered/N55854-2023-07-22), registration cancelled 2023-07-22, S/N 28-7305485, built 1973 (OpenAirDocs) - Reported make and model: PIPER PA28 (180) - Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-730-5485 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 28; injuries: serious; 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 (OpenAirDocs). - [Accident 20090211000929A](https://openairdocs.org/incident/20090211000929A), Feb 11, 2009: Piper PA28180, Pittstown, NJ, Substantial damage. The aircraft began takeoff on runway 25. It climbed to approximately 100 feet and lost engine power. Momentarily the aircraft regained full power and the pilot… ## Other investigations on N55854 (1) 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. - [NTSB NYC03LA096](https://openairdocs.org/ntsb/NYC03LA096), May 5, 2003: Piper PA-28-180 (N55854), Montgomery, NY, substantial damage. Probable cause: The inadequate 100-hour inspection by maintenance personnel, which resulted in a loose fuel line and loss of power. A factor related to the accident was the dark night conditions. 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.