LAX06CA191

NTSB accident investigation · Piper PA-28R-200 · Alpine, CA · June 4, 2006

Accident · No injuriesData collectionFinal report
Date
June 4, 2006, 12:56 local (19:56 UTC)
Place
Alpine, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4438TPiper PA-28R-200
Weather
Visual (VMC) · Day
Status
Completed · report October 3, 2006
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20060604013519A
Case key
63849

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

a loss of engine power due to the aviation maintenance technician's failure to install the correct oil sump quick drain, which resulted in the inadvertent draining of engine oil during flight.

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(partial) - mech failure/malfCruise
Lubricating system,oil quickdrain/drain plug - unapproved partCause
Maintenance,installation - improperCompany maintenance personnelCause
Fluid,oil - exhaustionCause
Forced landingDescent - emergency
On ground/water encounter with terrain/waterLanding - roll
Terrain condition - rough/uneven

Analysis

The airplane lost oil pressure in flight and was damaged in an encounter with rough terrain during a forced landing. The oil sump quick drain valve was replaced the day of the accident. On the first flight following the replacement, 2 quarts of oil were lost. The aviation maintenance technician retorqued the valve and the maintenance test flight was successful. The instructor departed on a local instructional flight with a student and about 50 minutes into the flight, oil pressure decreased and the engine revolutions per minute were fluctuating. The instructor shut down the engine and force landed the airplane. The installed oil sump quick drain valve, a Safe-Air 5000, had an extension of 1.9 inches. The approved Piper quick drain valve (Piper part number 492-172V) has an extension of 0.21-inch. Airworthiness Directive 81-11-02 R1 states that unapproved drain valves can cause inadvertent draining of oil when the gear is retracted and that only Piper approved parts should be used for the oil sump quick drain installation in this airplane model.

Factual narrative

On June 4, 2006, at 1256 Pacific daylight time, a Piper PA-28R-200, N4438T, lost oil pressure during flight and the certified flight instructor (CFI) made a precautionary landing in a field in Alpine, California. During the landing, the landing gear punctured through the wings and resulted in substantial damage. Anglo American Aviation International was operating the airplane under the provisions of 14 CFR Part 91. The CFI and private pilot undergoing instruction were not injured. Visual meteorological conditions prevailed and no flight plan had been filed for the local area instructional flight. The airplane departed from Gillespie Field, El Cajon, California, at 1200.

In an interview with the aviation maintenance technician (AMT) immediately following the accident, he stated that the oil sump quick drain valve was replaced on June 4. The AMT flew the airplane to Gillespie Field from Borrego Springs and noted a 2-quart loss of oil. The AMT replaced the oil and retorqued the newly installed valve. The CFI test flew the airplane and did not note any loss of oil.

The CFI reported that following the maintenance test flight, he departed with the student on the accident flight and approximately 50 minutes into the flight, the oil pressure decreased and the revolutions per minute were fluctuating. The CFI shut down the engine and performed a forced landing in a field.

In an interview with the operator, he reported that the installed quick drain was a Safe-Air P5000. Examination of the quick drain showed that this was the installed drain.

The Federal Aviation Administration issued airworthiness directive (AD) 81-11-02 R1 on October 2, 1981. The AD requires that within the next 50 hours time in service or at the next oil change, install two warning placards, one on each side, on the lower engine mount beneath the intake and the exhaust tubes which reads:

Caution

Unapproved oil drain valves can cause inadvertent draining when the gear is retracted- use only Piper approved part.

The AD also notes that Piper part number 492-172V is the approved part for this installation. In the closed position, the valve extension is 0.21-inch. The Safe-Air P5000 quick drain valve extension is 1.9 inches.

Aircraft

Registration
N4438T
Reported as
Piper PA-28R-200
Category
Airplane
Serial number
28R-7235050
Engine
Textron Lycoming IO-360, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Registered owner
Anglo American Aviation, Inc.
Airworthiness certificate
Standard, Normal
Departed
SEE · El Cajon, CA

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
Flight instructor
Age
24
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1
Flight hours
478 total · 52 in this make and model · 50 in the last 90 days · 17 in the last 30 days
Role
Pilot
Age
18
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 2

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
None

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.