LAX97LA266

NTSB accident investigation · Piper PA-28R-180 · Buckeye, AZ · July 31, 1997

Accident · Minor injuriesLimited investigationFinal report
Date
July 31, 1997, 08:14 local (15:14 UTC)
Place
Buckeye, AZ
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4667JPiper PA-28R-180
Weather
Visual (VMC) · Day
Status
Completed · report April 10, 1998
Report
Approved by Office Director
FAA report
19970731020859A
Case key
29857

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 total oil exhaustion of the engine due to the inadequate maintenance installation of the oil cooler lines by the owner/mechanic.

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) - mech failure/malfClimb
Lubricating system,oil hose - not securedCause
Maintenance,installation - inadequateOwner/pilot mechanicCause
Fluid,oil - exhaustionCause
Forced landingEmergency landing after takeoff
Nose overLanding - roll
Terrain condition - soft

Analysis

The owner of the airplane, who is a certified A & P mechanic, had complied with an AD which required the replacement of the oil cooler hose. He ran the engine up to idle but did not remove the engine cowling to check for signs of an oil leak. The airport manager stated he noticed a large oil puddle at the site where the airplane was started and a trail of oil leading out to the runway. The airplane climbed about 250 feet when the engine quit and a forced landing was made. The engine teardown revealed no oil in the engine, with heat distress noted to the bearings and journals, and the number 2 connecting rod separated from the crankshaft. One oil cooler line was loose and required an 180-degree turn to tighten the nut.

Factual narrative

On July 31, 1997, at 0814 hours mountain standard time, a Piper PA-28R-180, N4667J, collided with a dirt berm in a cotton field and nosed over following a forced landing near Buckeye, Arizona. The forced landing was precipitated by a total loss of engine power while the aircraft was climbing to a cruise altitude. The airplane sustained substantial damage. The private pilot who was in the left seat, and the owner, who was also a private pilot and in the right seat, sustained minor injuries. The airplane was operated as a personal flight under 14 CFR Part 91 when the accident occurred. The flight originated in Buckeye, and visual meteorological conditions prevailed at the time of the accident.

The owner of the airplane holds an FAA Airframe and Powerplant mechanic certificate, and performs the maintenance on the aircraft. Review of the maintenance records and an interview with the owner revealed that he had complied with AD 95-26-13, which required the replacement of the oil cooler hoses. This maintenance was performed on July 25, 1997. The owner said he replaced two oil cooler lines, then subsequently ran up the engine to idle, but did not remove the engine cowling to check for signs of an oil leak. According to Lycoming, the reported idle run/leak check was "most likely of a duration not sufficient to produce enough heat to activate the oil cooler by-pass valve, thus diverting the engine oil around the oil cooler. It is unlikely that a leak would have been detected until the engine obtained normal operating temperature." The airport manager noticed a large amount of oil from where the airplane was run up leading out to the runway for quite some distance.

The engine was torn down on August 7, 1997, at Air Transport, Phoenix, Arizona under the supervision of the Safety Board and a complete report of the examination is appended to this report. No lubricating oil was found within the engine. The engine was seized and the crankshaft would not rotate. Heat distress was observed to the internal bearings and journals, with the number 2 connecting rod separated from the crankshaft. The remaining engine rotating group components and valve train were examined further with no evidence of any other mechanical malfunction observed. The Lycoming engine representative noted that the "B" nut of the oil cooler line that attaches to the engine accessory case above the left magneto was loose and required an 180-degree turn to tighten.

The owner of the aircraft said that as the aircraft was descending he had to manually hold the emergency landing gear extension lever in the "override" position in order to keep the landing gear from extending. He told investigators that as the aircraft was about to land in the cotton field, he "let go of the lever in order to brace himself." The landing gear immediately extended. As the aircraft touched down in the field, it nosed over onto its back.

According to the Piper Aircraft Corporation representative on scene, the examination of the accident airplane revealed that the emergency landing gear override system had no lockout mechanism installed. On October 19, 1983, Piper Aircraft issued Service Bulletin No. 769 which recommended that aircraft equipped with back-up landing gear extension systems install a lockout mechanism. On March 4, 1988, Piper Aircraft issued Service Bulletin No. 866A allowing operators of aircraft equipped with back-up landing gear extension systems to either remove the system or review and understand all the information contained in the applicable airplane Flight Manual/Pilot's Operating Handbook pertaining to the normal and emergency operation of the system. Service Bulletin No. 866A requires aircraft affected by Service Bulletin No. 769 to comply with that bulletin prior to or concurrent with compliance with Service Bulletin No. 866A. Piper Aircraft considers compliance with Service Bulletin No. 866A mandatory.

Aircraft

Registration
N4667J
Reported as
Piper PA-28R-180
Category
Airplane
Serial number
28R-30566
Engine
Lycoming IO-360-B1E, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
William John Roberts
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 7, 1996 · 42 hours before
Departed
BXK · AZ
Destination
PRC · Prescott, AZ
Airport
BXK · Buckeye Muni

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
64
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
1,337 total · 1,220 as pilot in command · 9 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
50 statute miles
Lowest ceiling
None
Temperature
102 °F, dew point 50 °F
Altimeter
29.00 inHg
Observed at
GYR, 18 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.