# NTSB WPR14LA031: Piper PA 28-180, N30865, Big Creek, CA, October 24, 2013 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: October 24, 2013, 10:00 local (17:00 UTC) - Place: Big Creek, CA - Coordinates: 37.183612, -119.13861 - Nearby events: https://openairdocs.org/map.md?lat=37.1836&lon=-119.1386&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: Serious injuries - Injuries: 1 serious - Status: Completed, report September 29, 2014 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Lycoming, FAA, Piper - NTSB case key (mKey): 88311 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR14LA031 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88311/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88311 - Page: https://openairdocs.org/ntsb/WPR14LA031 ## 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 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 · Failure (probable cause); cases with it: [Piper PA-28-180, 5 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=7102808), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Maintenance: modification/alteration](https://openairdocs.org/ntsb-findings/02062030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-180, 1 case](https://openairdocs.org/ntsb-findings/02062030/cases.md?model=7102808), [All aircraft, 69 cases](https://openairdocs.org/ntsb-findings/02062030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-28-180, 37 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102808), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) ## 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](https://openairdocs.org/deregistered/N30865-2014-02-25), registration cancelled 2014-02-25, S/N 283619 (OpenAirDocs) - Reported make and model: PIPER PA 28-180 - Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 283619 - Airframe hours: 6553 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; injuries: serious; 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 ## 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 20131024022549A](https://openairdocs.org/incident/20131024022549A), Oct 24, 2013: Piper PA-28-180, Big Creek, CA, Substantial damage. On oct 24, 2013, [privacy data omitted] departed bishop, CA enroute to fresno chandler airport, fresno, CA. When level at cruise flight at 11, 500 he… ## Docket (18 files) The files NTSB released with the investigation on July 29, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88311. 9.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 247 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414493&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation - Co Owner (item 2, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414494&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Co%20Owner-Master.PDF - Fresno County Sheriff Report (item 3, .PDF, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414503&FileExtension=.PDF&FileName=Fresno%20County%20Sheriff%20Report-Redacted.PDF - Lycoming Exam Notes (item 4, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414504&FileExtension=.PDF&FileName=Lycoming%20Exam%20Notes-Master.PDF - Lycoming Review of Factual Report (item 5, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414505&FileExtension=.PDF&FileName=Lycoming%20Review%20of%20Factual%20Report-Redacted.PDF - Piper Review of Factual Report (item 6, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414506&FileExtension=.PDF&FileName=Piper%20Review%20of%20Factual%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 7, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414507&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 8, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414508&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Maintenance Logbook Excerpt (item 9, .PDF, 168 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414509&FileExtension=.PDF&FileName=Maintenance%20Logbook%20Excerpt-Redacted.PDF - Engine Record Logbook Cover Page (item 10, .PDF, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414510&FileExtension=.PDF&FileName=Engine%20Record%20Logbook%20Cover%20Page-Master.PDF - Photo 1. Right Side of Aircraft at Accident Site (item 11, .PDF, 712 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414495&FileExtension=.PDF&FileName=Photo%201.%20Right%20Side%20of%20Aircraft%20at%20Accident%20Site-Master.PDF - Photo 2. Cockpit Area (item 12, .PDF, 610 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414496&FileExtension=.PDF&FileName=Photo%202.%20Cockpit%20Area-Master.PDF - Photo 3. Right Rear View of Wreckage (item 13, .PDF, 799 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414497&FileExtension=.PDF&FileName=Photo%203.%20Right%20Rear%20View%20of%20Wreckage-Master.PDF - Photo 4. Right Wing Looking Aft (item 14, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414498&FileExtension=.PDF&FileName=Photo%204.%20Right%20Wing%20Looking%20Aft-Master.PDF - Photo 5. Right Side of Aircraft with Left Detached Wing (item 15, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414499&FileExtension=.PDF&FileName=Photo%205.%20Right%20Side%20of%20Aircraft%20with%20Left%20Detached%20Wing-Master.PDF - Photo 6. Engine After Recovery (item 16, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414500&FileExtension=.PDF&FileName=Photo%206.%20Engine%20After%20Recovery-Master.PDF - Photo 7. Broken Oil Sensor (item 17, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414501&FileExtension=.PDF&FileName=Photo%207.%20Broken%20Oil%20Sensor-Master.PDF - Photo 8. Electronic Oil Sensor (item 18, .PDF, 735 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40414502&FileExtension=.PDF&FileName=Photo%208.%20Electronic%20Oil%20Sensor-Master.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.