# NTSB LAX06CA191: Piper PA-28R-200, N4438T, Alpine, CA, June 4, 2006 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: June 4, 2006, 12:56 local (19:56 UTC) - Place: Alpine, CA - Coordinates: 32.818611, -116.763885 - Nearby events: https://openairdocs.org/map.md?lat=32.8186&lon=-116.7639&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report October 3, 2006 - Report: Approved by Office Director - Parties: Federal Aviation Administration - ADs cited in the narratives: [AD 81-11-02 R1](https://openairdocs.org/ad/81-11-02-R1) (OpenAirDocs) - NTSB case key (mKey): 63849 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX06CA191 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/63849/pdf - Page: https://openairdocs.org/ntsb/LAX06CA191 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - mech failure/malf, cruise - lubricating system,oil quickdrain/drain plug - unapproved part (cause) - maintenance,installation - improper, company maintenance personnel (cause) - fluid,oil - exhaustion (cause) - Forced landing, descent - emergency - On ground/water encounter with terrain/water, landing - 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](https://openairdocs.org/deregistered/N4438T-2008-04-09), registration cancelled 2008-04-09, S/N 28R-7235050, built 1972 (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-7235050 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 24; 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 - Pilot; age 18; 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 (OpenAirDocs). - [Accident 20060604013519A](https://openairdocs.org/incident/20060604013519A), Jun 4, 2006: Piper PA28R200, Alpine, CA, Substantial damage. (-23) During a 100 hour inspection of the aircraft, the oil drain plug was removed and a quick drain was installed. This quick drain was long enough to be… 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.