# NTSB LAX91LA075: Piper PA-28-201T, N9541C, Arcadia, CA, January 16, 1991

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Limited investigation · Final report
- Date: January 16, 1991, 09:27 local (17:27 UTC)
- Place: Arcadia, CA
- Coordinates: 34.129936, -118.019805 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=34.1299&lon=-118.0198&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Minor injuries
- Injuries: 2 minor
- Status: Completed, report December 30, 1992
- Report: Approved by Office Director
- NTSB case key (mKey): 27094
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX91LA075
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/27094/pdf
- Page: https://openairdocs.org/ntsb/LAX91LA075

## Probable cause

IMPROPER INSTALLATION OF THE RECENTLY OVERHAULED POWERPLANT BY MAINTENANCE PERSONNEL AND INADEQUATE INSPECTION BY MAINTENANCE PERSONNEL WHICH FAILED TO DETECT THAT THE ENGINE FUEL PRESSURE GAUGE LINE WAS NOT PROPERLY SECURED TO THE FUEL SYSTEM MANIFOLD VALVE.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power, cruise
  - fuel system,line - not secured (contributing factor)
  - maintenance,installation - improper, other maintenance personnel (cause)
  - maintenance,inspection - inadequate, other maintenance personnel (cause)
- Forced landing, descent - emergency
  - remedial action - not possible, pilot in command
- On ground/water collision with object, landing - roll
  - object - fence

## Analysis

THE AIRPLANE RECENTLY HAD ITS POWERPLANT OVERHAULED.  THE ACCIDENT FLIGHT WAS THE FIRST FLIGHT AFTER THE INSTALLATION OF THE OVERHAULED ENGINE. DURING CRUISE FLIGHT THE ENGINE LOST POWER.  THE AIRPLANE FORCE LANDED IN A PARKING LOT. DURING THE LANDING ROLL THE AIRPLANE STRUCK A FENCE AND SLID INTO A DITCH.  CFR PERSONNEL NOTICED FUEL LEAKING FROM UNDER THE ENGINE COWLING.  POST ACCIDENT EXAMINATION OF THE ENGINE REVEALED THE FUEL PRESSURE LINE FROM THE FUEL MANIFOLD VALVE TO THE FUEL PRESSURE GAUGE CAME LOOSE IN FLIGHT AT THE ENGINE FUEL MANIFOLD VALVE.

## Aircraft

- Registration: [N9541C](https://openairdocs.org/deregistered/N9541C-2014-11-24), registration cancelled 2014-11-24, S/N 28R-7803265, built 1978 (OpenAirDocs)
- Reported make and model: PIPER PA-28-201T
- Registry model: [Piper PA-28R-201T](https://openairdocs.org/model/piper-pa-28r-201t) (registry code 7102813) (OpenAirDocs)
- Registry engine: [Continental TSIO-360 series](https://openairdocs.org/engine/continental-tsio-360-series) (registry code 17019, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 28R-7803265
- Airframe hours: 1707
- Engines: CONTINENTAL TSIO-360FBIB 200 horsepower reciprocating
- Damage: Substantial damage
- Flight: Ferry, Part 91
- Operator: Dan E. Wolfe
- Registered owner: Dan E. Wolfe
- Airworthiness certificate: Standard, Normal
- Last inspection: 100 hour, January 14, 1991, 1 hours before
- Departed: BUR, BURBANK, CA
- Destination: L67, RIALTO, CA

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 25; flight instructor, airline transport, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, unknown; seat: left; flight hours: 2,820 total, 10 in this make and model, 2,195 as pilot in command, 128 in the last 90 days, 43 in the last 30 days, 1 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Visibility: 50 statute miles
- Lowest ceiling: none
- Altimeter: 30.00 inHg
- Observed at: EMT, 5 nm away

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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