LAX93LA088

NTSB accident investigation · Piper PA-28R-201T · Concord, CA · January 2, 1993

Accident · Minor injuriesLimited investigationFinal report
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.

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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.

Loss of engine power(total) - nonmechanicalCruise - normal
Lubricating system,oil pressure pump - looseCause
Maintenance,installation - improperManufacturerCause
Fluid,oil - pressure too low
Emergency procedure - performedPilot in command
Precautionary landing - initiatedPilot in command
Forced landingDescent - emergency
Terrain condition - none suitable
Terrain condition - residential area
On ground/water collision with objectLanding - flare/touchdown
Object - sign
Object - fence

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.