# NTSB ERA23LA144: Piper PA-28R-200, N9420N, Slaughters, KY, March 2, 2023

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Class 3 · Limited · Final report
- Date: March 2, 2023, 13:05 local (19:05 UTC)
- Place: Slaughters, KY
- Coordinates: 37.490436, -87.517488 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=37.4904&lon=-87.5175&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute-climb to cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340)
- Highest injury: No injuries
- Injuries: 1 uninjured
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Eastern Region Aviation
- Parties: FAA/FSDO
- NTSB case key (mKey): 106850
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA23LA144
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106850/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=106850
- Page: https://openairdocs.org/ntsb/ERA23LA144

## Probable cause

Maintenance personnel’s failure to secure the fuel strainer bowl with safety wire, which resulted in the fuel strainer bowl leaking and starving the engine of fuel. Also causal was the obstruction of two fuel injector nozzles.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Fuel system: fuel filter-strainer](https://openairdocs.org/ntsb-findings/01022821): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-28R-200, 2 cases](https://openairdocs.org/ntsb-findings/01022821/cases.md?model=7102811), [All aircraft, 52 cases](https://openairdocs.org/ntsb-findings/01022821/cases.md)
- [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28R-200, 4 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=7102811), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute-climb to cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Piper PA-28R-200, 6 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=7102811), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md)
- [Landing: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Piper PA-28R-200, 14 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=7102811), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md)

## Analysis

The pilot purchased an airplane that had not flown in 22 years and that had an extensive annual inspection completed the day before the accident flight. On the day of the accident, the pilot flew the airplane on a short flight to an airport and topped off the fuel tanks. About 5 minutes after he departed on the second leg, the engine started to lose power so he performed an off-airport forced landing. The airplane landed hard, which resulted in substantial damage to the wings. Postaccident examination of the airplane revealed that when electrical power was applied to the electric fuel pump, fuel leaked from the fuel strainer bowl. Further examination of the fuel strainer bowl revealed that the thumb wheel, which secured the fuel strainer bowl to the firewall, was loose and not secured with safety wire. Examination of the fuel system forward of the fuel strainer bowl revealed no fuel was present up to the fuel nozzles. Once the fuel strainer bowl was secured and the thumb wheel tightened, fuel flowed to the fuel nozzles and no leaks were noted. Additionally, one of the fuel injector nozzles was completely obstructed and another was partially obstructed. Since the fuel bowl was not safety wired, it likely loosened from vibration after the annual inspection which resulted in fuel leaking from the fuel strainer bowl. The fuel leak likely starved the engine of adequate fuel to operate normally, and contributed to the partial loss of engine power. The obstructed fuel injector nozzles also likely negatively impacted the engine’s performance during the flight.

## Factual narrative

On March 2, 2023, at 1305 central standard time, a Piper PA-28R-200, N9420N, was substantially damaged when it was involved in an accident near Slaughters, Kentucky. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he purchased the airplane in April 2021, and the airplane had not flown for 22 years. He hired a mechanic to complete an extensive annual inspection, and the mechanic endorsed the airplane’s logbooks on March 1, 2023. The pilot planned on flying the airplane back to San Diego, California. On the day of the accident, he flew from Bowman Field Airport (LOU), Louisville, Kentucky, to Madisonville Regional Airport (2I0), Madisonville, Kentucky, which was about 97 nautical miles. He topped off the fuel tanks at 2I0 and visited a friend in town for a couple hours before departing for Lebanon Springfield Airport-George Hoerter Field (6I2), Springfield, Kentucky. About 5 minutes after he departed 2I0, at an altitude of 1,600 ft mean sea level, the engine started to “lose power and slow down.” He did not remember if the engine was sputtering, he just remembered the engine was losing power. He knew he could not make it back to the airport, so he set up for a forced landing to a field. The airplane landed hard, and all three landing gear separated from their mounts. The main landing gear were forced up through the wings, which substantially damaged the wing ribs and main spar. Examination of the engine revealed that, when electrical power was applied to the electric fuel pump, fuel leaked from the fuel strainer bowl. The thumb wheel, which secured the fuel strainer bowl to the firewall, was loose and not secured with safety wire, which allowed fuel to exit the fuel strainer bowl. The fuel system forward of the fuel strainer was examined and no fuel was noted up to the fuel nozzles. The fuel strainer bowl was secured by the mechanic and when the fuel pump was powered up fuel flowed from the strainer bowl, through the fuel lines, to the fuel nozzles. The fuel nozzles were examined, and the No. 3 nozzle had a small piece of unidentified material in it and the No. 4 nozzle was totally clogged. The Nos. 1 & 2 nozzles were found clear of debris. No other anomalies were noted with the engine.

## Aircraft

- Registration: [N9420N](https://openairdocs.org/aircraft/N9420N), registered now, S/N 28R-35132 (OpenAirDocs)
- Reported make and model: PIPER PA-28R-200
- Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs)
- Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 28R-35132
- Airframe hours: 2550
- Engines: Lycoming IO-360-C1C 200 hp reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Operator: Space Cadets Inc
- Registered owner: Space Cadets Inc
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, March 1, 2023
- Departed: 210, Madisonville, KY
- Destination: SGF, Springfield, MO
- Airport: None
- Equipment: Auto-pilot, Electronic flight bag or handheld device, Handheld GPS, Satellite tracking device, Onboard weather, Heads up display, Stall warning system

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 76; injuries: none; private; airplane ratings: single-engine land; medical: class 2, with waivers/limitations; last flight review September 1, 2022; seat: left; restraint: 3-point; flight hours: 1,700 total, 16 in this make and model, 1,700 as pilot in command, 7 in the last 90 days, 7 in the last 30 days, 6 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 50 °F, dew point 30 °F

## 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 20230302002559A](https://openairdocs.org/incident/20230302002559A), Mar 2, 2023: Piper PA-28R-200, Madisonville, KY, Substantial damage. On March 2, 2023 at approximately 1840 UTC, pilot flying [privacy data omitted] departed runway 23 at Madisonville Regional Airport (2I0) on a cross country…

## Docket (8 files)

The files NTSB released with the investigation on May 9, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=106850. 33.0 MB in all.

- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15915253&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf
- Memorandum for record a�� telephone interview, pilot (item 2, PDF, 1 page, 118 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15915185&FileExtension=pdf&FileName=Record%20of%20Interview-pilot-Rel.pdf
- Engine examination report (mechanic) (item 3, PDF, 2 pages, 811 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15914737&FileExtension=pdf&FileName=N9420N%20insp%20report_Redacted-Rel.pdf
- Maintenance records (item 4, PDF, 5 pages, 13.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15914289&FileExtension=pdf&FileName=maintenance%20records_Redacted-Rel.pdf
- Piper service manual (item 5, PDF, 1,024 pages, 15.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15938137&FileExtension=pdf&FileName=Piper%20Service%20manual-Rel.pdf
- Piper service manual (excerpts) (item 6, PDF, 4 pages, 541 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15938232&FileExtension=pdf&FileName=excerpts%20from%20Service%20manaul-Rel.pdf
- Investigative photographs (item 7, PDF, 4 pages, 966 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15913946&FileExtension=pdf&FileName=Investigative%20Photo%27s-Rel.pdf
- Release of aircraft wreckage, NTSB form 6120.15 (item 8, PDF, 1 page, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15915263&FileExtension=pdf&FileName=Wreckage%20release_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.

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