# NTSB ERA22FA261: Piper PA-28RT-201, N160LL, Panama City, FL, June 6, 2022 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: June 6, 2022, 16:10 local (21:10 UTC) - Place: Panama City, FL - Coordinates: 30.323999, -85.775898 - Nearby events: https://openairdocs.org/map.md?lat=30.3240&lon=-85.7759&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Fatal - Injuries: 2 fatal, 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Lycoming Engines, FAA/FSDO, Piper Aircraft - NTSB case key (mKey): 105200 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA22FA261 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105200/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105200 - Page: https://openairdocs.org/ntsb/ERA22FA261 ## Probable cause Maintenance personnel’s failure to follow the avionics installation guidance for the oil pressure sensor, which resulted in the high-cycle fatigue failure of an line, oil starvation, and the subsequent loss of engine power. Contributing to the accident was the pilot’s failure to perform an adequate preflight inspection of the airplane. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Incorrect service/maintenance; cases with it: [Piper PA-28RT-201, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=7102818), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel; cases with it: [Piper PA-28RT-201, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=7102818), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Incorrect service/maintenance; cases with it: [Piper PA-28RT-201, 1 case](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=7102818), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot; cases with it: [Piper PA-28RT-201, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=7102818), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Fatigue/wear/corrosion; cases with it: [Piper PA-28RT-201, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=7102818), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340); cases with it: [Piper PA-28RT-201, 1 case](https://openairdocs.org/ntsb-events/340/sequence.md?model=7102818), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Piper PA-28RT-201, 3 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7102818), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) ## Analysis The pilot was conducting a personal flight with two passengers aboard. Security camera video revealed that when the pilot arrived at the airplane prior to initiating the flight, he did not perform a complete preflight inspection, which should have included at least a cursory examination of the airplane’s engine and a check of the ground below it. Shortly after departure, the pilot declared an emergency, and the airplane made a 180° left turn back toward the airport. The airplane descended and impacted terrain about 1.7 miles from the runway threshold. Postaccident examination of the engine revealed that the crankcase was breached near the No. 4 cylinder. Also, the No. 4 connecting rod journal exhibited thermal damage and bearing material was found welded/smeared to the crankshaft journal. The No. 4 connecting rod cap, connecting rod bolts, and bearing pieces were found in the oil sump along with other metallic debris and a trace amount of oil. Examination of the oil system revealed that the oil pressure sensor was separated from the engine. The sensor’s rigid copper line was fractured at the fitting to the accessory section of the crankcase. The propeller exhibited chordwise scratching and angle-cut tree branches in the vicinity of the wreckage, which were indications that the engine did not lose total power. Examination of the rigid oil pressure line revealed that it fractured due to high-cycle fatigue. This was likely from excessive vibration due to insufficient support of the oil pressure sensor and rigid line. The oil pressure sensor, which was part of the avionics system, was installed about 3 flight hours before the accident. The installation manual for the avionics system stated that a flexible line should be used to install the oil pressure sensor in order to minimize vibration effects. Instead, a rigid line was installed, which would have been more susceptible to the effects of vibration, including high-cycle fatigue failure. Oil staining observed on the ramp area where the airplane was parked before the flight, a trail of oil leading from the parking area to the runway, and the oil observed on the airframe exterior at the accident site all suggest that the airplane was actively leaking oil both before and during the accident flight. Based on all available information, it is likely that the oil pressure sensor line fractured during the flight before the accident flight, which resulted in oil leaking from the engine. This oil leak ultimately resulted in oil starvation and loss of engine power during the departure from, and the pilot’s attempted return to the airport. Had the pilot noted and investigated the source of the oil leakage during the preflight inspection, he might have taken appropriate corrective action and avoided the accident. ## Factual narrative According to the most recent annual inspection, the airplane had a tachometer time of 508.6 hours. During the annual inspection, a new avionics system was installed, which included a Dynon Skyview HDX panel display and a Dynon electronic flight instrument system. The airframe maintenance logbook indicated that the work was performed by five people, one of whom was the pilot, and was signed off by a mechanic with inspection authorization. Additionally, Federal Aviation Administration Form 337, Major Repairs and Alterations, indicated that the installation of the Dynon Skyview HDX was performed in accordance with Dynon Skyview HDX System Installation Manual, dated October 28, 2020. The installation manual stated the following: Mount the oil pressure sensor securely to the airplane’s structure using appropriate AN/MS hardware fittings, clamps, and flexible hose…. DO NOT mount the sensor directly to engine or other areas of high vibration. Always mount the sensor to the airframe structure, and connect it with flexible hose to minimize vibration effects. Mounting the sensor directly to the engine may cause sensor failure/leakage and possibly fire. According to the airplane flight log, the tachometer time on June 5, 2022, was 511.5 hours. Furthermore, on an entry dated May 25, 2022, the entry indicated that the pilot flew the airplane with “Fly Test” written next to his name. Postaccident examination of the pavement in the parking area of the FBO revealed a trail of oil drops that led to a small puddle of oil where the airplane was initially parked. A second larger area of oil staining, measuring about 6 ft by 6 ft (as shown in figure 2), was found at the airplane’s second parking location (where the airplane had been moved by FBO personnel), which was where the pilot conducted his walk-around and loaded passengers before he started the engine for taxi and takeoff. Furthermore, there was a trail of oil leading from the spot pictured in Figure 2 toward the runway that aligned with the airplane taxiing to the runway. Figure 2 - Large oil stain on the pavement where airplane was located at engine start. On June 6, 2022, about 1610 central daylight time, a Piper PA-28RT-201, N160LL, was substantially damaged when it was involved in an accident near Northwest Florida Beaches International Airport (ECP), Panama City, Florida. The pilot and one passenger were fatally injured, and another passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. On the morning of the accident, the pilot and passengers arrived at ECP, and the pilot parked the airplane on a local fixed-base operator (FBO) ramp about 0941. About 1100, the FBO moved the airplane to another location on the ramp because the pilot and passengers were not returning until later in the day. A review of the data downloaded from an onboard avionics system revealed that during the flight to ECP, the oil pressure initially stabilizedat 89 pounds per square inch (psi) and decreased gradually as oil temperature increased. Immediately before takeoff power was set, the oil pressure had reduced to about 50 psi. The oil pressure remained steady at 80 psi during the flight. After landing, the oil pressure ranged between 50 and 70 psi (depending on the engine power setting). A review of security camera video revealed that the pilot returned to the airplane about 1530. He opened the baggage compartment, entered and exited the cockpit multiple times, walked around the front of the airplane, and stopped in front of each wing until the two passengers arrived about 1541. During these 11 minutes, he did not appear to spend any appreciable time inspecting the airplane’s engine or the ground below it. About 1551, the airplane exited the FBO ramp and taxied to runway 34. Onboard avionics system data showed that immediately after the engine was started for the accident flight, the oil pressure stabilized at about 67 psi. The oil pressure gradually decreased as the oil temperature increased and continued decreasing as the aircraft taxied to the runway. Immediately before takeoff, the oil pressure had reduced to about 10 psi. When the engine was advanced to takeoff power, the oil pressure dropped to 4 psi. According to automatic dependent system broadcast (ADS-B) data, the airplane began the takeoff roll about 1606 and reached a peak altitude of about 1,200 ft mean sea level (msl). According to summary of air traffic control communications, the pilot declared an emergency about 1609. ADS-B data showed that the airplane began to descend, made a 180° left turn, and then continued to descend until it impacted trees and terrain about 1.7 miles from the runway threshold. The ADS-B data ended about 190 ft before the main wreckage; figure 1 shows the airplane’s flight track. Figure 1 - ADS-B data showing the accident flight track. According to the pilot’s logbook, on May 25, 2022, the pilot performed a flight that the logbook described as “TEST ARROW”. The airplane came to rest upright in an area of dense brush at an elevation of 25 ft. All major components of the airplane were located near the main wreckage. Multiple tree branches located along the debris path exhibited black paint transfer and were cut at 45° angles. Flight control cable continuity was established from the cockpit to the flight control surfaces. Oil was noted along the bottom right side of the fuselage. The three-blade propeller remained attached to the engine. The spinner was impact damaged, all blades remained attached to the hub, and one of the blades exhibited chordwise scratching. Postaccident examination of the engine revealed a breach of the crankcase near the No. 4 cylinder. The engine was disassembled, and continuity of the crankshaft was confirmed. No anomalies were noted on the main journals of the crankshaft. The No. 4 connecting rod journal exhibited thermal damage, and bearing material was found welded/smeared to thecrankshaft journal. The No. 4 connecting rod cap, connecting rod bolts, and bearing pieces were found in the oil sump along with other metallic debris and a trace amount of oil. The oil drain plug remained seated and safety wired to the oil sump. The oil pump rotated freely by hand. The oil pump was disassembled, and no scoring was noted on the oil pump gears or the housing. The oil pressure sensor was separated from the engine. The sensor’s rigid copper line was fractured at the fitting to the accessory section of the crankcase, as shown in figure 3. Figure 3. Fractured oil pressure sensor line. The rigid copper line and oil pressure sensor were examined by the National Transportation Safety Board Materials Laboratory. The examination revealed that most of the fracture occurred on a flat plane perpendicular to the tube axis, and a darker region with a smooth curving boundary was observed at one side identified as the origin area, as shown in figure 4. The figure also shows that fatigue features emanated from the origin area and extended to the boundary approximately indicated with dashed lines. The remainder of the fracture surface showed a change in fracture plane with dimple features on the fracture surface; those features were consistent with ductile overstress fracture of the remaining ligament of the tube wall. Figure 4. Oil pressure sensor line fracture surface after cleaning. The dashed lines indicate the approximate fatigue boundary from the origin area, which is indicated with a bracket. ## Aircraft - Registration: [N160LL](https://openairdocs.org/deregistered/N160LL-2024-01-29), registration cancelled 2024-01-29, S/N 28R-7918157, built 1979 (OpenAirDocs) - Reported make and model: PIPER PA-28RT-201 - Registry model: [Piper PA-28RT-201](https://openairdocs.org/model/piper-pa-28rt-201) (registry code 7102818) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7918157 - Year built: 1979 - Airframe hours: 3956.73 - Engines: Lycoming IO-360-C1C6 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 11, 2022 - Departed: ECP, Panama City, FL - Destination: ORL, Orlando, FL - Airport: ECP, Northwest Florida Beaches International Airport, runway 16/34, 10,000 × 150 ft - Equipment: Electronic primary flight display, Electronic multifunction display, Auto-pilot, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 310 total, 216 in this make and model, 156.6 as pilot in command, 58.6 in the last 90 days, 19.3 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 72 °F - Altimeter: 29.85 inHg - Observed at: ECP, 2 nm away - METAR: KECP 062053Z 19010KT 10SM SCT050 30/22 A2985 RMK AO1 LTG DSNT NW SLP119 T03000222 56019 ## 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 20220606009689A](https://openairdocs.org/incident/20220606009689A), Jun 6, 2022: Piper PA-28RT-201, Panama City, FL, Destroyed, 2 fatal. The aircraft departed ecp, climbing to the south. Approximately one minute into the flight the pilot declared an emergency with fire in the cockpit and… ## Docket (19 files) The files NTSB released with the investigation on November 8, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105200. 1.5 GB in all. - Witness statements (item 1, PDF, 3 pages, 231 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14307328&FileExtension=pdf&FileName=01-03Witness%20Interview%20Summaries-3-Rel.pdf - Pilot's logbook (item 2, PDF, 32 pages, 1.4 GB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14307385&FileExtension=pdf&FileName=02-01Pilot%20Logbook%20FA261_Redacted-Rel.pdf - Fuel reciept (item 3, PDF, 1 page, 519 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14306541&FileExtension=pdf&FileName=01-04Fuel%20Receipt%20N160LL_Redacted-Rel.pdf - Flight track diagrams (item 4, PDF, 3 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14307187&FileExtension=pdf&FileName=05-02Flight%20Track%20Diagrams-3-Rel.pdf - Air traffic control summary transcript (item 5, PDF, 3 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14306799&FileExtension=pdf&FileName=05-03ATC%20Summary%20Transcript-3-Rel.pdf - Investigative photographs (item 6, PDF, 5 pages, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14307395&FileExtension=pdf&FileName=06-01Investigative%20Photographs%20FA261-5-Rel.pdf - Wreckage examination summary (item 7, PDF, 29 pages, 8.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14307473&FileExtension=pdf&FileName=06-03Wreckage%20Examination%20Summary%20FA261-29-Rel.pdf - Maintenance records - excerpts (item 8, PDF, 3 pages, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14496180&FileExtension=pdf&FileName=Excerpt%20from%20Mx%20Logs%20FA261_Redacted-Rel.pdf - FAA form 337 - major repair and alteration form - avionics installation (item 9, PDF, 2 pages, 914 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14495646&FileExtension=pdf&FileName=FAA%20337%20Form%20FA261_Redacted-Rel.pdf - Dynon skyview hdx installation manual - excerpts (item 10, PDF, 5 pages, 196 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14495750&FileExtension=pdf&FileName=Dynon%20Skyview%20HDX%20Installation%20Manual%20Excerpts-Rel.pdf - Toxicological report - pilot (item 11, PDF, 1 page, 176 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14960097&FileExtension=pdf&FileName=Pilot%20Tox%20Report%20FA261_Redacted-Rel.pdf - Toxicological report - passenger (item 12, PDF, 1 page, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14960338&FileExtension=pdf&FileName=Passenger%20Tox%20Report%20FA261_Redacted-Rel.pdf - Memorandum for record a�� security camera footage timeline (item 13, PDF, 2 pages, 195 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14307405&FileExtension=pdf&FileName=08-04Memorandum%20Of%20Record%20-%20Security%20Camera%20Footage%20Timeline-2-Rel.pdf - Materials laboratory factual report 22-058 (item 14, PDF, 3 pages, 3 photos, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14308659&FileExtension=pdf&FileName=22-058-Rel.pdf - Memorandum for record - autopsy (item 15, PDF, 1 page, 198 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14472185&FileExtension=pdf&FileName=Autopsy%20Memorandum%20Of%20Record%20Color-Rel.pdf - Recorded flight data specialist's factual report (item 16, PDF, 12 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14944310&FileExtension=pdf&FileName=Recorded%20Data%20Report_FINAL-Rel.pdf - Recorded flight data specialist's factual report - attachment 1 (item 17, CSV, 524 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14944813&FileExtension=csv&FileName=Recorded%20Flight%20Data%20Report%20-%20Attachment%201-Rel.csv - Recorded flight data specialist's factual report - attachment 2 (item 18, CSV, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14944663&FileExtension=csv&FileName=Recorded%20Data%20Report%20-%20Attachment%202-Rel.csv - Release of aircraft wreckage, NTSB form 6120.15 (item 19, PDF, 1 page, 34.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14957944&FileExtension=pdf&FileName=N160LL%20NTSB%20Release%20Signed_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.