# NTSB LAX93LA088: Piper PA-28R-201T, N2008M, Concord, CA, January 2, 1993

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Limited investigation · Final report
- Date: January 2, 1993, 13:45 local (21:45 UTC)
- Place: Concord, CA
- Coordinates: 38.000045, -122.030311 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=38.0000&lon=-122.0303&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Minor injuries
- Injuries: 1 minor
- Status: Completed, report November 15, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 27902
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX93LA088
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/27902/pdf
- Page: https://openairdocs.org/ntsb/LAX93LA088

## 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

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

- Loss of engine power(total) - nonmechanical, cruise - normal
  - lubricating system,oil pressure pump - loose (cause)
  - maintenance,installation - improper, manufacturer (cause)
  - fluid,oil - pressure too low
  - emergency procedure - performed, pilot in command
  - precautionary landing - initiated, pilot in command
- Forced landing, descent - emergency
  - terrain condition - none suitable
  - terrain condition - residential area
- On ground/water collision with object, landing - 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](https://openairdocs.org/deregistered/N2008M-1993-03-17), registration cancelled 1993-03-17, S/N 28R7803099 (OpenAirDocs)
- Reported make and model: PIPER PA-28R-201T (PA-28R-201)
- Registry model: [Piper PA-28R-201T](https://openairdocs.org/model/piper-pa-28r-201t) (registry code 7102813) (OpenAirDocs)
- Category: Airplane
- Serial number: 28R-7803099
- Airframe hours: 2227
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 49; 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 (OpenAirDocs).

- [Accident 19930102000119A](https://openairdocs.org/incident/19930102000119A), Jan 2, 1993: Piper PA28R201T, Concord, CA, Substantial damage. Lost oil pressure,hot oil smell. Vectored to Concord. Crashed short. Pump cover came off. Lock nut tabs not locked.

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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