WPR15LA141

NTSB accident investigation · Piper PA 28R-200 · Santa Maria, CA · April 4, 2015

Accident · Minor injuriesLimited investigationFinal report
Date
April 4, 2015, 11:31 local (18:31 UTC)
Place
Santa Maria, CA
Injuries
2 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N5469TPiper PA 28R-200
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report January 5, 2016
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20150404007919A
Case key
90990

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 engine failure due to oil starvation, which resulted from the installation of an unapproved oil quick drain valve that subsequently led to the inadvertent draining of the oil when the nose landing gear was retracted. Contributing to the accident was the lack of required warning placards on the engine mounts.

Findings · 3

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: unauthorized maint/repairPersonnel issues › Task performance · Maintenance personnelPiper PA-28R-200: 2 casesAll aircraft: 14 casesProbable cause
Fluids: oilAircraft › Fluids/misc hardware · Fluid levelPiper PA-28R-200: 4 casesAll aircraft: 174 casesProbable cause
Placards and markingsAircraft › Aircraft handling/service · Not installed/availablePiper PA-28R-200: 1 caseAll aircraft: 11 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 reported that, during climbout, while the airplane was about 3,500 ft mean sea level, the engine lost partial power. He then turned the airplane back toward the airport. Shortly thereafter, the engine lost all power, and the pilot chose to initiate a forced landing to a nearby field about 4 miles southeast of the airport. During postaccident examination of the engine, two cracks were observed on the upper portion of the engine crankcase near the No. 2 cylinder mounting surface. The crankshaft would not rotate by hand. Oil residue was observed on the left lower portion of the engine cowling and on the airplane's belly. A minimal amount of oil was observed in the oil filter and oil sump. Review of the airplane's maintenance records revealed that an oil quick drain valve was installed on the engine 2 days before the accident. An aircraft manufacturer service letter (SL) and an airworthiness directive (AD) had been issued about 14 years before the accident to inform maintenance personnel about which oil quick drain valve should be installed on the accident make and model airplane. The SL provided a sketch of both the incorrect and correct oil quick drain valves, and the AD provided the approved part number. Examination of the engine revealed that the incorrect oil quick drain valve was installed on the engine. When the nose landing gear (NLG) assembly was actuated into its up-and-locked position, the bolt connecting the NLG assembly struck the oil quick drain valve, and several impact marks were present. It is likely that this damage resulted in the loss of oil and subsequent oil starvation to the engine. The AD also required that two warning placards be installed, one on each side of the engine mounts, stating that unapproved oil quick drain valves can cause inadvertent draining when the gear is retracted and to use only the manufacturer-approved part to prevent the loss of oil due to the installation of an incorrect oil quick drain valve. No placards were observed on the engine mounts.

Factual narrative

On April 4, 2015, about 1131 Pacific daylight time, a Piper PA-28R-200, N5469T, sustained substantial damage during a forced landing following a reported loss of engine power, near the Santa Maria Public Airport (SMX) Santa Maria, California. The airplane was registered and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. The two Airline Transport Pilots sustained minor injuries and the passenger was not injured. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight. The local flight originated from SMX about 1120. The pilot reported that during climb out, about 3,500 feet mean sea level (msl), the engine lost partial power, and he turned the airplane back towards the airport. Shortly thereafter, the pilot stated that the engine lost all power and he elected to initiate a forced landing to a nearby clearing. The airplane came to rest upright, in a strawberry field about 4 miles southeast from SMX. Examination of the airplane by a Federal Aviation Administration inspector revealed that the wings sustained substantial damage during the forced landing. The airplane was recovered to a secure storage facility for further examination. Further examination of the recovered wreckage by the National Transportation Safety Board investigator-in-charge revealed that both wings and the horizontal stabilizers were previously removed to facilitate transport of the wreckage. The engine remained attached to the airframe. Examination of the Lycoming Motors IO-360-C1C engine revealed that all accessories and cylinders remained attached to their respective mounts. Two cracks were observed on the upper portion of the engine crankcase near the number two cylinder mounting surface. The crankshaft would not rotate by hand. An oil quick drain oil valve was installed on the engine. According to the Piper Service Letter number 910, Subject Engine Quick Drain Valve, dated December 29, 1980, was issued to make maintenance personnel aware of the correct oil quick drain valve installment on the PA-28-200 model airplane. The letter then provides a sketch of the incorrect oil quick drain valve and the correct oil quick drain valve. According to the service letter, the oil quick drain valve installed on the airplane was consistent with the sketch of the incorrect valve. Further, Airworthiness Directive (AD) 81—11-02 R1, stated "to prevent possible loss of oil due to installation of an incorrect engine oil quick drain valve, to accomplish the following: Install two warning placards, one on each side of the engine mounts…"caution, unapproved oil drain valves can cause inadvertent draining when the gear is retracted-use only manufacturer approved part". The AD goes on to state the approved part number. The installed oil quick drain valve part number on the accident airplane did not match the approved part number. The AD states "if an incorrect valve is installed, replace it with the approved partnumber". Further, no warning placards were observed on the accident airplane's engine mounts. When the nose gear assembly was actuated into its up and locked position, the bolt connecting the nose gear assembly would strike the oil quick drain valve. Several impact marks were present on the oil quick drain valve and the nose gear assembly bolt, consistent with them striking each other. Oil residue was observed on the left lower portion of the engine cowling and on the belly of the airplane. A minimal amount of oil was observed in the oil filter and oil sump. No oil residue was observed on, or near the cracks in the crankcase. In summary, the examination of the engine revealed that an incorrect oil quick drain valve was installed. Postaccident examination of the recovered airframe and engine revealed no additional anomalies that would preclude normal operation. An FAA Inspector's review of the airplane's maintenance records revealed that oil quick drain valve was installed on April 2, 2015.

Aircraft

Registration
N5469T
Reported as
Piper PA 28R-200 (200)
Category
Airplane
Serial number
28R-7235233
Built
1972
Airframe hours
6,819.4
Engine
Lycoming IO360 SER, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 2, 2015
Departed
SMX · Santa Maria, CA
Destination
SMX · Santa Maria, CA
Airport
SMX · Santa Maria Public Airport.
Equipment
Stall warning system, Auto-pilot

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
33
Injuries
Minor
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
November 10, 2014
Seat
Left
Restraint
3-point
Flight hours
4,850 total · 1,100 in this make and model · 80 in the last 90 days
Role
Pilot
Age
64
Injuries
Minor
Certificates
Airline transport, Flight engineer
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Airplane
Last flight review
June 1, 2014
Seat
Right
Restraint
3-point
Flight hours
22,000 total · 600 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 13 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
72 °F, dew point 39 °F
Altimeter
29.96 inHg
Observed at
SMX, 4 nm away

Docket · 6

The files NTSB released with the investigation on November 24, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.1 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.