WPR10LA165

NTSB accident investigation · Piper PA-28R-200 · Eliza Island, WA · March 17, 2010

Accident · No injuriesLimited investigationFinal report
Date
March 17, 2010, 11:00 local (18:00 UTC)
Place
Eliza Island, WA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N1KUPiper PA-28R-200
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report April 12, 2011
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
FAA FSDO
FAA report
20100317029599A
Case key
75546

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 loss of engine power during cruise flight due to the failure of maintenance personnel to tighten a fitting on the propeller governor oil line, which resulted in a loss of engine oil and catastrophic engine failure.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Engine (reciprocating): recip eng oil sysAircraft › Aircraft power plant · Incorrect service/maintenancePiper PA-28R-200: 3 casesAll aircraft: 130 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · FailurePiper PA-28R-200: 7 casesAll aircraft: 497 casesProbable cause
Object/animal/substance: poleEnvironmental issues › Physical environment · Effect on equipmentPiper PA-28R-200: 3 casesAll aircraft: 142 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported that the airplane had recently underwent an annual inspection and the accident flight was to be the first flight after the maintenance. After about 10 to 15 minutes into the flight, the engine experienced a total loss of power. During a forced landing to a grass strip, the pilot turned the controls over to his more experienced pilot-rated passenger to perform the landing. As the airplane slowed for landing, the automatic landing gear extension system deployed the landing gear. The airplane subsequently landed short of the runway and the right wing struck a post. The fuselage was twisted and both wings were bent/wrinkled as a result. A postaccident examination of the engine revealed that the crankcase was cracked and the bottom of the fuselage was covered with oil. The oil was traced to originate from a fitting that attached the propeller governor high-pressure oil line from the nose of the crankcase to the propeller governor. The fitting was found to be loose and likely not adequately tightened by maintenance personnel. Maintenance records indicated that during the annual inspection the propeller governor on the engine's accessory section had been removed in an effort to replace its gasket.

Factual narrative

On March 17, 2010, approximately 1100 Pacific daylight time, a Piper Arrow PA-28R-200, N1KU, sustained substantial damage during a forced landing following a loss of engine power near Eliza Island, Washington. The private pilot/owner and the pilot-rated passenger were not injured. The owner was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the local maintenance test flight, which had been airborne for approximately 15 minutes. A flight plan had not been filed; the flight departed from Bellingham, Washington. The pilot/owner stated that the airplane had just been annually inspected and was signed off on February 24, 2010. Due to bad weather and other commitments, he could not perform a maintenance flight until March 17, 2010. On that day, he invited a fellow pilot and occasional flight instructor to join him. During their extensive preflight, it was noted that the engine crankcase contained 7 quarts of oil. The engine start and taxi out were normal; the before takeoff run-up was "a bit longer than usual," which gave time to confirm good engine oil pressure. The magnetos checked normal and the propeller cycled normally. The pilot/owner performed the takeoff and climbed to 4,800 feet. After 8 to 10 minutes of flight, the propeller went to low pitch and the engine to high rpm. The propeller did not respond to the propeller control. A forced landing spot was selected to a grass strip on a small island. The engine began making metal grinding noises and vibrating heavily. Soon thereafter, the engine froze and the propeller stopped. The pilot-rated passenger took control of the airplane and performed a forced landing. During this time, the airplane's automatic landing gear extension system lowered the landing gear earlier than the flying pilot had planned. The airplane landed short of the runway, and struck a 3-foot-high beach piling with its right wing root. The fuselage was twisted, and both wings were bent and wrinkled. Examination of the engine revealed that the crank case was cracked and the bottom of the fuselage was covered with oil. After aircraft recovery to a salvage yard, a National Transportation Safety Board investigator examined the engine on April 7, 2010. He found that the fitting which attached the propeller governor high pressure oil line from the nose of the crankcase to the propeller governor was loose. Maintenance records indicated that during the annual inspection, the propeller governor on the engine's accessory section had been removed so that its gasket could be replaced.

Aircraft

Registration
N1KU
Reported as
Piper PA-28R-200
Category
Airplane
Serial number
28R-7135161
Airframe hours
3,278
Engine
Lycoming IO-360 SER, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Prater Keith B
Registered owner
Prater Keith B
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 24, 2010
Departed
BLI · Bellingham, WA
Destination
BLI · Bellingham, WA
Flight plan
Unknown
Airport
WA93 · Eliz Island Airport, runway 16, 1,500 × 75 ft, grass/turf

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
66
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
April 22, 2009
Seat
Left
Flight hours
474 total · 221 in this make and model · 368 as pilot in command · 7 in the last 90 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
48 °F, dew point 36 °F
Altimeter
30.53 inHg
Observed at
BLI, 9 nm away

Docket · 4

The files NTSB released with the investigation on December 1, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.7 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.