# NTSB WPR10LA165: Piper PA-28R-200, N1KU, Eliza Island, WA, March 17, 2010 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: March 17, 2010, 11:00 local (18:00 UTC) - Place: Eliza Island, WA - Coordinates: 48.653888, -122.586944 - Nearby events: https://openairdocs.org/map.md?lat=48.6539&lon=-122.5869&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report April 12, 2011 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA FSDO - NTSB case key (mKey): 75546 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR10LA165 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/75546/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=75546 - Page: https://openairdocs.org/ntsb/WPR10LA165 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-28R-200, 3 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=7102811), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-28R-200, 7 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=7102811), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Piper PA-28R-200, 3 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=7102811), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Object/animal/substance: pole](https://openairdocs.org/ntsb-findings/03022010): Environmental issues › Physical environment · Effect on equipment; cases with it: [Piper PA-28R-200, 3 cases](https://openairdocs.org/ntsb-findings/03022010/cases.md?model=7102811), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/03022010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Piper PA-28R-200, 7 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=7102811), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-28R-200, 32 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102811), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28R-200, 30 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102811), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28R-200, 45 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102811), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N1KU-2010-07-22), registration cancelled 2010-07-22, S/N 28R-7135161, built 1971 (OpenAirDocs) - Reported make and model: PIPER PA-28R-200 - Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7135161 - Airframe hours: 3278 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; injuries: none; 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 ## 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 20100317029599A](https://openairdocs.org/incident/20100317029599A), Mar 17, 2010: Piper PA-28R-200, Eliza Island, WA, Substantial damage. Aircraft left bli, about 7 miles out engine surged, then quit, dead sticked it into Eliza Island, grass strip, on landing, gear hit burm, gear detached,… ## Docket (4 files) The files NTSB released with the investigation on December 1, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=75546. 3.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40339279&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 2, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40339280&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Engine Examination Report with 48 Embedded Photos (item 3, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40339281&FileExtension=.PDF&FileName=Engine%20Examination%20Report%20with%2048%20Embedded%20Photos-Master.PDF - Maintenance Page (item 4, .PDF, 289 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40339282&FileExtension=.PDF&FileName=Maintenance%20Page-Redacted.PDF 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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.