# NTSB ERA12LA469: Piper PA-28-180, N3692R, Statesboro, GA, July 20, 2012 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: July 20, 2012, 14:00 local (18:00 UTC) - Place: Statesboro, GA - Coordinates: 32.482776, -81.736946 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.4828&lon=-81.7369&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: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report December 19, 2012 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 84396 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA12LA469 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/84396/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=84396 - Page: https://openairdocs.org/ntsb/ERA12LA469 ## Probable cause A total loss of engine power as a result of oil exhaustion due to the mechanic's failure to apply appropriate torque to the oil filter. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28-180, 6 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=7102808), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-28-180, 5 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=7102808), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Piper PA-28-180, 4 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=7102808), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) - [Maintenance/inspections: return to service](https://openairdocs.org/ntsb-findings/01010530): Aircraft › Aircraft handling/service · Inadequate inspection (probable cause); cases with it: [Piper PA-28-180, 1 case](https://openairdocs.org/ntsb-findings/01010530/cases.md?model=7102808), [All aircraft, 14 cases](https://openairdocs.org/ntsb-findings/01010530/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Contributed to outcome (probable cause); cases with it: [Piper PA-28-180, 14 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=7102808), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/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) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-180, 96 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102808), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Piper PA-28-180, 5 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=7102808), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis About 5 minutes after takeoff, the airplane experienced a total loss of engine power and impacted a row of trees during the resultant forced landing. The accident flight was the first following a 100-hour maintenance inspection. The pilot/mechanic reported that he had changed the engine oil and oil filter as part of that inspection; however, he did not utilize a torque wrench to tighten the filter as required. Oil was noted on the ground, beginning in the area outside of the hangar doors where the maintenance was performed to the departure runway. Postaccident examination revealed that the filter was secured in place with a safety wire; however, it was able to be freely rotated by hand to the extent of that wire. It is likely that during the operation of the engine on the accident flight, oil escaped around the oil filter, which resulted in oil exhaustion and subsequent seizure of the engine. ## Factual narrative On July 20, 2012, about 1400 eastern daylight time, a Piper PA-28-180, N3692R, experienced a total loss of engine power about 5 minutes after takeoff from the Statesboro-Bulloch County Airport (TBR), Statesboro, Georgia and the pilot/mechanic subsequently made an off airport forced landing to a peanut field. The certificated private pilot sustained minor injuries and a passenger was not injured. The airplane sustained substantial damage to the wings and fuselage. The airplane was registered to a private individual and was operated under the provisions of 14 Code of Federal Regulations Part 91 as a maintenance test flight. Visual meteorological conditions prevailed and no flight plan had been filed for the local flight. The pilot/mechanic reported that prior to the flight he had completed a 100 hour maintenance inspection on the airplane which included an oil and oil filter change. After the inspection he operated the engine inside an airport hangar at 1500 rpm and had detected no oil leaks. He subsequently pulled the airplane out of the hangar, performed an engine run-up with full power, and determined that the engine was operating as expected. He taxied to runway 14, performed another high power run-up, and departed on the local maintenance flight. Shortly after departure, approximately 800 feet above ground level, he noted a loss of oil pressure and subsequent total loss of engine power. Initial examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed that it came to rest in a tree line, at the edge of a field, slightly nose down, and the right wing had been impact separated by a tree. The stabilator was impact separated. Evidence of blight was noted on the vegetation in the vicinity of the accident airplane; however, the fuel line to the carburetor was devoid of fuel. A follow-up examination by an FAA inspector, which coincided with the recovery of the airplane, revealed oil streaking around the lower nose gear truss and along the underside of the fuselage. Further examination revealed that the crankshaft was seized. Examination of the engine revealed that the oil dipstick tube was impact damaged. Examination of the oil filter revealed that it was hand tight and the safety wire was secured; however, the oil filter was able to rotate counter clockwise to the extent of the safety wire. The pilot/mechanic confirmed that he had not utilized any torque device to tighten the oil filter. Examination of the hangar where the maintenance had been performed revealed, outside the hangar doors, a large area of oil on the ground as well as an oil trail from that hangar to the departure end of runway 14. According to the Lycoming Publication titled "Lycoming Flyer," 18 to 20 foot pounds of torque should be applied when installing an oil filter on the engine. However, it further states that the 20 foot pound maximum torque should not be exceeded. ## Aircraft - Registration: [N3692R](https://openairdocs.org/deregistered/N3692R-2018-01-04), registration cancelled 2018-01-04, S/N 28-5269, built 1970 (OpenAirDocs) - Reported make and model: PIPER PA-28-180 - 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: 28-5269 - Airframe hours: 5758 - Engines: LYCOMING O-360 A4A 180 horsepower reciprocating - Damage: Substantial damage - Flight: Flight test, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, July 20, 2012, 0 hours before - Departed: TBR, Statesboro, GA - Destination: TBR, Statesboro, GA - Airport: TBR, Statesboro-Bulloch County ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; injuries: none; private; airplane ratings: single-engine land; medical: class 3; last flight review December 30, 2011; seat: left; flight hours: 347 total, 250 in this make and model, 289 as pilot in command, 2 in the last 90 days, 2 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: 5,000 ft broken - Temperature: 90 °F, dew point 72 °F - Altimeter: 30.03 inHg - Observed at: TBR, 3 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 20120720024509A](https://openairdocs.org/incident/20120720024509A), Jul 20, 2012: Piper PA-28-180, Statesboro, GA, Substantial damage. On July 21 at 1030 am approximately an inspector from this office arrived at Statesboro ga. Specifically a location in a tree line between a peanut field and… ## Docket (8 files) The files NTSB released with the investigation on October 25, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=84396. 12.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - Pilot (item 1, .PDF, 455 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374411&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20Pilot-Redacted.PDF - Memorandum of Record - FAA Notes (Excerpts) (item 2, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40377055&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20-%20FAA%20Notes%20(Excerpts)-Master.PDF - Aircraft Maintenace Logs (item 3, .PDF, 492 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40373827&FileExtension=.PDF&FileName=Aircraft%20Maintenace%20Logs-Redacted.PDF - Excerpts from Lycoming Flyer Publication (item 4, .PDF, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40377064&FileExtension=.PDF&FileName=Excerpts%20from%20Lycoming%20Flyer%20Publication-Master.PDF - Statesboro Georgia Weather (item 5, .PDF, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40373663&FileExtension=.PDF&FileName=Statesboro%20Georgia%20Weather-Master.PDF - Photo 1: Airplane At Rest (Courtesy of the FAA) (item 6, .PDF, 4.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374414&FileExtension=.PDF&FileName=Photo%201%3A%20Airplane%20At%20Rest%20(Courtesy%20of%20the%20FAA)-Master.PDF - Photo 2: Left Side of Airplane (Courtesy of the FAA) (item 7, .PDF, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374416&FileExtension=.PDF&FileName=Photo%202%3A%20Left%20Side%20of%20Airplane%20(Courtesy%20of%20the%20FAA)-Master.PDF - Photo 3: Oil on the Tarmac in Front of the Hangar (Courtesy of the FAA) (item 8, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374417&FileExtension=.PDF&FileName=Photo%203%3A%20Oil%20on%20the%20Tarmac%20in%20Front%20of%20the%20Hangar%20(Courtesy%20of%20the%20FAA)-Master.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.