# NTSB WPR15LA141: Piper PA 28R-200, N5469T, Santa Maria, CA, April 4, 2015 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: April 4, 2015, 11:31 local (18:31 UTC) - Place: Santa Maria, CA - Coordinates: 34.907775, -120.515556 - Nearby events: https://openairdocs.org/map.md?lat=34.9078&lon=-120.5156&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 2 minor, 1 uninjured - Status: Completed, report January 5, 2016 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 90990 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR15LA141 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90990/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90990 - Page: https://openairdocs.org/ntsb/WPR15LA141 ## 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oil quick drain valve that subsequently led to the inadvertent draining of the oil when the nose landing gear was retracted.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 NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: unauthorized maint/repair](https://openairdocs.org/ntsb-findings/02062040): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28R-200, 2 cases](https://openairdocs.org/ntsb-findings/02062040/cases.md?model=7102811), [All aircraft, 14 cases](https://openairdocs.org/ntsb-findings/02062040/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Piper PA-28R-200, 4 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=7102811), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) - [Placards and markings](https://openairdocs.org/ntsb-findings/01011100): Aircraft › Aircraft handling/service · Not installed/available (probable cause); cases with it: [Piper PA-28R-200, 1 case](https://openairdocs.org/ntsb-findings/01011100/cases.md?model=7102811), [All aircraft, 11 cases](https://openairdocs.org/ntsb-findings/01011100/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: 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) - [Landing: 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) ## 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](https://openairdocs.org/deregistered/N5469T-2016-05-18), registration cancelled 2016-05-18, S/N 28R-7235233, built 1972 (OpenAirDocs) - Reported make and model: PIPER PA 28R-200 (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-7235233 - Year built: 1972 - Airframe hours: 6819.4 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 33; injuries: minor; 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 - Pilot; age 64; injuries: minor; 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 ## 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 20150404007919A](https://openairdocs.org/incident/20150404007919A), Apr 4, 2015: Piper PA-28R-200, Santa Maria, CA, Substantial damage. On April 4, 2015, N5469T, a Piper PA-28R-200, crashed in a strawberry field approximately 3 miles east of the Santa Maria airport (ksmx). N5469T had just… ## Docket (6 files) The files NTSB released with the investigation on November 24, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90990. 3.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 521 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434277&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Airframe and Engine Examination Report (item 2, .PDF, 3 photos, 418 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434278&FileExtension=.PDF&FileName=Airframe%20and%20Engine%20Examination%20Report-Master.PDF - FAA Airworthiness Directive (item 3, .PDF, 132 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434279&FileExtension=.PDF&FileName=FAA%20Airworthiness%20Directive-Master.PDF - Piper Service Letter 534A (item 4, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434280&FileExtension=.PDF&FileName=Piper%20Service%20Letter%20534A-Master.PDF - Piper Service Letter 910 (item 5, .PDF, 845 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434281&FileExtension=.PDF&FileName=Piper%20Service%20Letter%20910-Master.PDF - Invoice of Installed Oil Drain Valve (item 6, .PDF, 148 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434282&FileExtension=.PDF&FileName=Invoice%20of%20Installed%20Oil%20Drain%20Valve-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.