WPR14LA031

NTSB accident investigation · Piper PA 28-180 · Big Creek, CA · October 24, 2013

Accident · Serious injuriesLimited investigationFinal report
Date
October 24, 2013, 10:00 local (17:00 UTC)
Place
Big Creek, CA
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N30865Piper PA 28-180
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report September 29, 2014
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Lycoming, FAA, Piper
FAA report
20131024022549A
Case key
88311

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The loss of engine power due to the improper installation of an oil pressure sending unit by the pilot, who was not a certificated mechanic, which resulted in a forced landing in mountainous terrain.

Findings · 2

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.

Maintenance: modification/alterationPersonnel issues › Task performance · PilotPiper PA-28-180: 1 caseAll aircraft: 69 casesProbable cause

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, who was a co-owner of the airplane, reported to an air traffic controller about 1 hour into a cross-country flight over mountainous terrain that the engine had lost oil pressure and then power. The pilot performed a forced landing into trees. Postaccident examination revealed that the loss of engine power resulted from oil starvation due to oil leaking from a fractured fitting at the oil pressure gauge/sending unit port on the engine's rear accessory case. An oil pressure sending unit, which the pilot, who was not a certificated mechanic, had installed at this location just before the accident flight, was found dangling by its electrical wiring harness and not supported. The sending unit was not approved for installation on this airplane. It is likely that the fitting fractured because of vibration due to the sending unit's lack of support. The engine operating time between the installation of the sending unit and the fitting fracture was about 1 hour.

Factual narrative

On October 24, 2013, about 1000 Pacific daylight time, a Piper PA-28-180, N30865, was substantially damaged when it impacted trees and terrain during a forced landing following a loss of engine power near Big Creek, California. The private pilot, the sole occupant onboard, was seriously injured. The airplane was owned by the pilot and another individual, and it was being operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91. No flight plan had been filed for the personal cross-country flight. The airplane had departed Bishop, California, approximately 1 hour before the accident; its planned destination was Fresno, California. Visual meteorological conditions prevailed in the vicinity of the accident site. According to the Federal Aviation Administration (FAA), the pilot reported to an air traffic controller that the airplane's engine lost oil pressure and then lost power. The pilot performed a forced landing into trees at an elevation of about 8,200 feet in the mountainous terrain of the Sierra National Forest. Examination of photographs taken at the accident site by recovery personnel revealed that the airplane's wings, fuselage, and empennage were bent and wrinkled. After the airplane was recovered to the facilities of Plain Parts in Pleasant Grove, California, it was examined under the supervision of a National Transportation Safety Board (NTSB) investigator on December 5, 2013. The examination revealed that there was engine oil coating the left rear side of the engine and extending down the left side of the fuselage. The source of the oil was found to be a fractured fitting at the oil pressure gage/sending unit port located on the left side of the engine's accessory case cover. An oil pressure sending unit, which appeared to be new, had been installed at this location, and the sending unit was found dangling by its electrical wiring harness. The sending unit and attached fittings measured about 2.5 inches in length, and the sending unit was not supported in any fashion. The engine case exhibited a bulging signature between the number 2 and number 4 cylinders consistent with an internal mechanical malfunction due to oil starvation. No further internal examination of the engine was performed. It was noted during the examination that the engine had been modified by the installation of an electronic fuel injection and ignition system manufactured by Electronic Fuel Injection and Ignition (EFII) of Upland, California. According to the company's website, www.flyefii.com, its systems are intended for use on experimental category aircraft. The most recent maintenance entry in the engine's maintenance logbook was made on July 10, 2013, by the co-owner of the airplane (who was not an FAA-certified mechanic) at a recording tachometer time of 3,446.01 hours. The logbook entry for this date stated, "annual insp. completed, oil and filter, replaced all cylinders and pistons with first run Lycoming O/H, EFII electronicignition." There was no record in the logbook of the installation of a new oil pressure sending unit. During a telephone interview conducted by the NTSB investigator-in-charge, the co-owner reported that the pilot (who also was not an FAA-certified mechanic) told him that he had installed the oil pressure sending unit just before the accident flight.

Aircraft

Registration
N30865
Reported as
Piper PA 28-180
Category
Airplane
Serial number
283619
Airframe hours
6,553
Engine
Lycoming O&VO-360 SER, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Peterson Arnie D
Registered owner
Peterson Arnie D
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 18, 2012
Departed
BIH · Bishop, CA
Destination
FCH · Fresno, CA
Equipment
Stall warning system

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
51
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3
Seat
Left
Flight hours
2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 18 °F
Altimeter
30.12 inHg
Observed at
BIH, 44 nm away

Docket · 18

The files NTSB released with the investigation on July 29, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.4 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.