- Date
- January 2, 1993, 13:45 local (21:45 UTC)
- Place
- Concord, CA
- Injuries
- 1 minor
- Damage
- Substantial damage
- Phase of flight
- Enroute
- Aircraft
- N2008MPiper PA-28R-201T
- Weather
- Visual (VMC) · Day
- Status
- Completed · report November 15, 1993
- Report
- Approved by Office Director
- FAA report
- 19930102000119A
- Case key
- 27902
From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.
On this page
Probable cause
The engine manufacturer failing to properly install tab washers during overhaul which resulted in one bolt becoming loose and being ingested through various engine gear drives. The ingestion and loose oil pump cover resulted in the engine running rough and a burning smell which caused the pilot to have to shut down the engine.
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.
Analysis
During an IFR flight at about 11,000 feet MSL, the airplane's engine began to run rough and the engine oil pressure dropped to zero. The pilot also said he smelled something that was burning. The pilot entered a descent and requested vectors to the nearest airport. While on the vector, the engine began to run rougher and the burning smell became stronger. The pilot shut down the engine and entered a power off forced landing. He broke out of the clouds and determined that he could not glide to the airport. He performed a landing to the only available area. During touchdown, the airplane collided with posts. An FAA safety inspector examined the engine. He determined that 1 of the 4 bolts used to bolt the engine oil pump cover to the crankcase was missing. A damaged bolt was found in the engine's camshaft gear. The tab washers used to lock the oil pump cover bolts had their single tab bent downward. The tab washers' twin tabs on the 3 remaining bolts were pointed straight out. They appeared to have never been bent into place after the bolts were tightened. Improper installation of the washers resulted in one bolt falling off and being ingested through various drive gears. The engine was overhauled by the manufacturer 515 hours prior to the accident.
Aircraft
- Registration
- N2008M
- Reported as
- Piper PA-28R-201T (PA-28R-201)
- Category
- Airplane
- Serial number
- 28R-7803099
- Airframe hours
- 2,227
- Engine
- Continental TSIO-360-FB3, 200 horsepower, reciprocating
- Damage
- Substantial damage
- Flight
- Personal · Part 91
- Operator
- Richard Talley/Larry Shattuck
- Registered owner
- Richard Talley/Larry Shattuck
- Airworthiness certificate
- Standard, Normal
- Last inspection
- Annual · September 30, 1992 · 50 hours before
- Departed
- O56 · Navato, CA
- Destination
- CCB · Upland, CA
- Flight plan
- IFR
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
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot
- Age
- 49
- Certificate
- Private
- Airplane ratings
- Single-engine land
- Instrument ratings
- Airplane
- Medical
- Class 3, Valid Medical--w/ waivers/lim
- Seat
- Left
- Flight hours
- 716 total · 62 in this make and model · 628 as pilot in command · 20 in the last 90 days · 3 in the last 30 days · 1 in the last 24 hours
Weather
- Conditions
- Visual (VMC) · Day
- Wind
- 350° at 4 knots
- Visibility
- 30 statute miles
- Lowest ceiling
- 5,000 ft broken
- Temperature
- 48 °F, dew point 34 °F
- Altimeter
- 30.00 inHg
- Observed at
- CCR, 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.