FTW01LA068

NTSB accident investigation · Piper PA32-R-301T · Haslet, TX · February 17, 2001

Accident · Serious injuriesLimited investigationFinal report
Date
February 17, 2001, 12:35 local (18:35 UTC)
Place
Haslet, TX
Injuries
1 serious, 3 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N8355LPiper PA32-R-301T
Weather
Visual (VMC) · Day
Status
Completed · report February 5, 2002
Report
Approved by Office Director
Parties
Textron Lycoming, FAA FSDO
FAA report
20010217004139A
Case key
51757

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

the improper installation of the oil filter bypass valve by an unknown person, which resulted in the loss of engine oil and subsequent loss of total power during a normal descent. A contributing factor to the accident was the lack of suitable terrain for the forced landing.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - mech failure/malfDescent - normal
Lubricating system,oil regulator - blocked(total)Cause
Maintenance,installation - improperUnknownCause
Lubricating system - pressure excessiveCause
Lubricating system,oil filter/screen - collapsed
Lubricating system,oil gasket - leakCause
Fluid,oil - loss,total
Forced landingDescent - emergency
Complete gear collapsedLanding - flare/touchdown
Terrain condition - none suitableFactor
Terrain condition - soft

Analysis

The airplane was approximately 40 minutes into the flight and 4 miles south of the destination airport in a normal descent when the propeller increased to maximum RPM. Shortly thereafter, the oil pressure light illuminated, and the pilot noticed the oil pressure gauge was indicating zero. Subsequently, the engine lost power, and the pilot elected to land in a field approximately 2 miles south of the runway threshold. The airplane touched down on soft ground, separating its landing gear. A post-accident examination of the engine revealed that there was no oil remaining in the engine, the oil filter internal element was collapsed inward, the oil filter converter plate gasket was found separated from the plate and broken in half, and the oil filter bypass valve was found installed improperly. The collapsed oil filter element and blown converter plate gasket are indicative of a cold weather and/or a high RPM start. With cold oil, the oil pressure became excessive due to the faulty bypass valve resulting in collapse of the filter and failure of the oil filter converter plate gasket.

Factual narrative

On February 17, 2001, at 1235 central standard time, a Piper PA32-R-301T single-engine airplane, N8355L, was substantially damaged during a forced landing following a loss of engine power near Haslet, Texas. The airplane was registered to a private individual and operated by Hest Aviation of Temple, Texas. The commercial flight instructor and pilot-rated passenger were seriously injured, and one passenger sustained minor injuries. Visual meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 personal flight. The flight originated from Killeen, Texas, at 1145, and was destined for the Fort Worth Alliance Airport, Fort Worth, Texas.

According to the pilot's written statement, the airplane was approximately 40 minutes into the flight and 4 miles south of the destination airport, when the "propeller increased to maximum RPM. Shortly thereafter, the oil pressure light illuminated." The pilot added that he noticed the oil pressure gauge was indicating "zero." The pilot performed the emergency checklist and notified air traffic control of the emergency. Subsequently, the engine "seized," and the pilot elected to land in a field approximately 2 miles south of the runway 34L threshold. The airplane touched down on the soft ground, separating its landing gear. The airplane came to rest upright.

Examination of the airplane by the FAA inspector, who responded to the accident site, revealed that the fuselage was buckled and both wings were damaged. The engine was checked for oil and none was found. The wreckage was taken to Air Salvage of Dallas, Lancaster, Texas, for further examination.

On April 26, 2001, the NTSB investigator-in-charge and an engine manufacturer representative examined the Lycoming TIO-540-S1AD engine (serial number L-7631-61A). During the examination of the engine, it was noted that the engine oil dipstick did not indicate an oil quantity and the propeller could not be rotated. The oil filter and the oil filter converter plate were removed, and it was noted that the oil filter's interior element was collapsed inward, and the oil filter converter plate gasket was found separated from the plate and broken in half. The oil filter, oil filter converter plate, and the oil filter converter plate gasket were sent to the engine manufacturer's facility for further examination.

According to the engine manufacturer, the oil converter plate gasket part number could not be determined; however, their materials laboratory determined that the rubber gasket material was "non-conforming." It was also noted that the gasket "had not been glued to the surface of the oil filter converter plate." According to Textron Lycoming Service Instruction (SI) 1453, dated May 9, 1991, the oil filter converter plate gasket must be bonded to the converter plate using 3M Scratch Grip Industrial Adhesive No. 847. The manufacturer reported that it was possible that the collapsed oil filter element could have occurred "due to a sticking oil filter bypass valve."

On July 11, 2001, an NTSB investigator and an engine manufacturer representative examined the engine's oil filter bypass valve. The valve was removed and examined. It was noted that the valve was installed incorrectly. According to Textron Lycoming SI 1442, the oil filter bypass valve is composed of 5 pieces; a spacer (part number 55K21022), a spring (part number 55C21021), a seat (part number 76539), a sleeve (part number LW-10320), and a ring (part number MS16625-1100), installed in that order. During the examination, the seat was found located in front of the spacer, which according to Lycoming, would have prevented the proper operation of the oil filter bypass valve. According to Textron Lycoming, if the oil filter bypass valve fails to operate, the oil filter element could collapse during a cold weather and/or high RPM start with cold oil.

According to the aircraft maintenance records, the engine was field overhauled and re-installed on the accident airplane on June 25, 1992, at a tachometer time of 1,317.2 hours. On February 3, 1997, the oil filter converter plate gasket was replaced at a tachometer time of 2,017.0 hours (699.8 hours since the 1992 overhaul). At the time of the accident, the engine had accumulated approximately 981 hours since its last overhaul.

Aircraft

Registration
N8355L
Reported as
Piper PA32-R-301T
Category
Airplane
Serial number
32R-8129051
Airframe hours
2,239.4
Engine
Lycoming TIO-540-S1AD, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Hest Aviation
Registered owner
Larry Herrera
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 31, 2000 · 58.6 hours before
Departed
ILE · Killeen, TX
Destination
AFW · Haslet, TX
Airport
AFW · Fort Worth Alliance, runway 34L

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
32
Injuries
Serious
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Last flight review
September 30, 2000
Seat
Right
Flight hours
2,100 total · 100 in this make and model · 1,400 as pilot in command · 34 in the last 30 days · 1 in the last 24 hours
Role
Co-pilot
Age
31
Injuries
Serious
Certificates
Military, Private, Commercial
Airplane ratings
Single-engine land
Instrument ratings
Helicopter
Medical
Class 2, Valid Medical--no waivers/lim.
Last flight review
June 30, 2000
Seat
Left
Flight hours
1,101 total

Weather

Conditions
Visual (VMC) · Day
Wind
360° at 17 knots, gusting 23
Visibility
6 statute miles
Lowest ceiling
None
Temperature
45 °F

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 N8355L · 1

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