# NTSB LAX04LA084: Piper PA-32R-300, N589Q, Riverside, CA, January 1, 2004 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: January 1, 2004, 09:20 local (17:20 UTC) - Place: Riverside, CA - Coordinates: 33.880001, -117.258331 - Nearby events: https://openairdocs.org/map.md?lat=33.8800&lon=-117.2583&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed, report June 8, 2005 - Report: Approved by Office Director - Parties: Federal Aviation Administration - ADs cited in the narratives: [AD 2000-18-53](https://openairdocs.org/ad/2000-18-53), AD 2002-12-17 (OpenAirDocs) - NTSB case key (mKey): 58581 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX04LA084 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58581/pdf - Page: https://openairdocs.org/ntsb/LAX04LA084 ## Probable cause engine oil exhaustion due to the extrusion of an oil filter converter plate gasket and the failure of the aircraft owner to comply with a mandatory Service Bulletin and a Federal Aviation Administration emergency Airworthiness Directive. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, cruise - lubricating system,oil gasket - ruptured (cause) - fluid,oil - exhaustion - maintenance,compliance with ad - not performed, company/operator management (cause) - Forced landing, emergency descent/landing - On ground/water collision with object, landing - flare/touchdown - object - fence - object - pole ## Analysis Following a catastrophic engine failure in cruise, the airplane collided with multiple ground obstacles during a forced landing in a field. The pilot reported that while in cruise flight he first noticed a "burning smell," which was followed a short time later by a low oil pressure indication. The pilot then felt a vibration, followed by a brief engine overspeed to 3,000 rpm, and then the engine lost all power. He performed a forced landing in a field and collided with multiple ground obstacles. Post accident examination of the engine at the accident site revealed that the No. 6 connecting rod had penetrated the engine crank case. An excess of engine oil was found on the bottom of the airplane. Further examination revealed an oil filter gasket, Lycoming part number LW-13388, was extruded at the base of the filter assembly and had allowed virtually all engine oil to escape. A Lycoming Mandatory Service Bulletin MSB-543, and an emergency Airworthiness Directive (AD) 2000-18-53, that was later superceded by AD 2002-12-17, was applicable to this potential problem, and required repetitive inspections and gasket replacement or replacement of the gasket adapter plate with a different part number. The investigation could find no evidence of compliance with either AD. ## Factual narrative On January 1, 2004, at 0920 Pacific standard time, a Piper PA-32R-300, N589Q, lost engine power and force landed in a field at Riverside, California. The airplane was operated by the pilot under the provisions of 14 CFR Part 91. The private pilot and three passengers were not injured, and the airplane was substantially damaged. Visual meteorological conditions prevailed, and no flight plan had been filed. The flight originated at Oceanside, California, at 0850, and was destined for Big Bear, California. The pilot reported that while in cruise flight he first noticed a "burning smell," which was followed a short time later by a low oil pressure indication. The pilot then felt a vibration, followed by a brief engine overspeed to 3,000 rpm, and then lost engine power. He performed a forced landing in a field 1/2 mile northeast of March ARB and collided with multiple ground obstacles. Post accident examination of the engine by a Federal Aviation Administration (FAA) inspector at the accident site revealed that the No. 6 connecting rod had penetrated the engine crank case. An excess of engine oil was found on the bottom of the airplane. Further examination revealed an oil filter gasket, Lycoming part number LW-13388 was extruded at the base of the filter assembly. The engine accessory case and the firewall was oil soaked. On September 5, 2000, the FAA issued emergency Airworthiness Directive (AD) 2000-18-53, which was applicable to Lycoming IO-540-K1G5D engines. That AD was prompted by reports of certain oil filter converter plate gaskets, P/N LW-13388, extruding from the seat of the oil filter converter plate. The protruding or swelling of the gasket allowed oil to leak from between the plate and accessory housing. According to the text of the AD, it was intended to prevent complete loss of engine oil and subsequent seizing of the engine and possible fire, caused by oil leakage between the converter plate and accessory housing. The AD required the following: 1. For engines with more than 50 hours time-since-new (TSN), time-since-overhaul (TSO), or time-since-last replacement of the oil filter plate gasket, replacement of the oil filter converter plate gasket part number (P/N) LW-13388, or the converter plate kit P/N LW-13904. 2. For engines with fewer than 50 hours TSN, TSO, or time-since-last replacement of the oil filter converter plate gasket P/N LW-13388, or the converter plate kit P/N LW-13904, inspection of the oil filter base for signs of oil leakage and evidence of gasket extrusion. 3. Replacement of converter plate gasket P/N LW-13388 at intervals not to exceed 50 hours TIS since the last replacement of the gasket. The actions are required to be done in accordance with Textron Lycoming Mandatory Service Bulletin (MSB) 543A, dated August 30, 2000, and Textron Lycoming Service Instruction number 1453, dated May 9, 1991. After emergency AD 2000-18-53 was issued, Textron Lycoming has issued a service bulletin supplement that relieves the requirements of MSB 543A and that eliminates the need for gasket replacement every 50 hours TSN, TSO, or time since the last replacement. AD 2002-12-17, which supercedes AD 2000-18-53, was then issued by the FAA and required the following actions: 1. Before further flight after the effective date of the AD, for engines with more than 50 hours TSN or TSO, or time-since-last replacement of the oil filter plate gasket P/N LW-13388, replacement of the oil filter converter plate gasket or the converter plate kit P/N LW-13904. 2. Within 10 hours TIS or within 3 days after the effective date of this AD, whichever occurs earlier, for engines with fewer than 50 hours TSN, TSO, or time-since-last replacement of the oil filter converter plate gasket P/N LW-13388, or the converter plate kit P/N LW-13904, inspection of the oil filter base for signs of oil leakage and evidence of gasket extrusion. 3. Replacement of the converter plate gasket P/N LW-13388 at intervals not to exceed 50 hours TIS since the last replacement of the gasket. 4. As terminating action to the repetitive gasket replacement specified in this AD, replacement of the oil filter converter plate gasket or the oil filter converter plate with a converter plate kit, in accordance with Part II and Part III of Textron Lycoming Supplement 1 to MSB 543A, dated October 4, 2000. The investigation could find no evidence that either of the AD's were complied with. ## Aircraft - Registration: [N589Q](https://openairdocs.org/deregistered/N589Q-2004-06-08), registration cancelled 2004-06-08, S/N 32R-7780492, built 1977 (OpenAirDocs) - Reported make and model: Piper PA-32R-300 - Registry model: [Piper PA-32R-300](https://openairdocs.org/model/piper-pa-32r-300) (registry code 7103213) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 32R-7780492 - Airframe hours: 4924 - Engines: Textron Lycoming IO-540-KIG5D 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Michael Woodin - Registered owner: Airtravel Enterprises Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 9, 2003, 38 hours before - Departed: OKB, Oceanside, CA - Destination: L35, BIG BEAR, CA - Airport: RIV, March Air Reserve Base ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 43; injuries: none; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; seat: left; flight hours: 300 total ## Weather - Conditions: Visual (VMC), Day - Visibility: 50 statute miles - Lowest ceiling: 20,000 ft broken - Temperature: 43 °F, dew point 34 °F - Altimeter: 30.20 inHg - Observed at: KRIV, 1 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 20040101001299A](https://openairdocs.org/incident/20040101001299A), Jan 1, 2004: Piper PA32R300, Riverside, CA, Substantial damage. (-23) On 1 jan, 2004, at approximately 0920 hours, a Piper PA-32R-300, N589Q, lost engine power and force landed in a sod field in Riverside California near… 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.