# NTSB WPR18LA101: Piper PA28R, N33807, Paso Robles, CA, March 7, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: March 6, 2018, 22:26 local (Mar 7, 2018, 06:26 UTC) - Place: Paso Robles, CA - Coordinates: 35.672779, -120.62694 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.6728&lon=-120.6269&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: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: FSDO - NTSB case key (mKey): 96834 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR18LA101 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96834/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96834 - Page: https://openairdocs.org/ntsb/WPR18LA101 ## Probable cause The pilots' inadequate preflight inspection, which failed to ensure that the oil filler cap was secured and resulted in oil starvation and a total loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28R-200, 2 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=7102811), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Student/instructed pilot (probable cause); cases with it: [Piper PA-28R-200, 2 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=7102811), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Incorrect use/operation (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) ## 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-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 flight instructor and private pilot receiving instruction completed a touch-and-go landing in night visual meteorological conditions. During the initial climb, they heard a "loud tick" noise, then the low vacuum annunciator light illuminated. About 350 to 400 ft above ground level, the engine lost all power, and the propeller came to a complete stop. The flight instructor took control of the airplane and performed a forced landing to a nearby field, during which the airplane sustained substantial damage to the wings and aft fuselage. Examination revealed that the oil filler cap was not secured, and that the engine contained about 1 quart of oil. In addition, oil was splattered on the inside of the engine compartment. It is likely that the pilots failed to secure the oil filler cap during the preflight inspection, which resulted in the loss of engine oil inflight, eventual oil starvation, and the total loss of engine power. ## Factual narrative On March 6, 2018, about 2226 Pacific standard time, a Piper PA-28R-200 airplane, N33807, was substantially damaged when it was involved in an accident near Paso Robles, California. The flight instructor and private pilot receiving instruction were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The instructor reported that, before the flight, he watched as the airplane was fueled to capacity and he checked the engine oil level, which was 6 quarts. He then asked the pilot receiving instruction to conduct a preflight inspection while he went inside. Upon returning to the airplane, he verbally confirmed the fuel and engine oil levels with the pilot and they subsequently departed. The flight was uneventful, and they performed a touch-and-go landing at the destination airport. During takeoff following the touch-and-go, the pilots heard a "loud tick" noise, followed by the illumination of the low vacuum annunciator light. The instructor took control of the airplane, retracted the landing gear, and instructed the pilot to retract the wing flaps; about 350 to 400 ft above ground level, the airplane stopped climbing, the engine lost all power, and the propeller came to a complete stop. The instructor performed a forced landing to a nearby field. During the landing roll, the wings and aft fuselage were substantially damaged. The following day, a Federal Aviation Administration inspector examined the wreckage and noted that the oil filler cap was not secured, and that the engine contained about 1 quart of oil. In addition, oil was splattered inside the engine compartment. (see Figure 1.) Figure 1. Loose oil cap visible through the access panel on the engine cowling ## Aircraft - Registration: [N33807](https://openairdocs.org/deregistered/N33807-2019-10-04), registration cancelled 2019-10-04, S/N 28R-7535198, built 1975 (OpenAirDocs) - Reported make and model: Piper PA28R (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-7535198 - Year built: 1969 - Airframe hours: 11933.5 - Engines: LYCOMING IO-360-C1C reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Utility - Last inspection: Annual, February 2, 2018 - Departed: RHV, San Jose, CA - Destination: PRB, Paso Robles, CA - Airport: PRB, Paso Robles Muni, runway 13, 4,701 × 100 ft, asphalt - Equipment: Stall warning system, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; seat: left; restraint: 3-point; flight hours: 411 total, 14 in this make and model, 49 in the last 90 days - Flight instructor; age 23; injuries: none; flight instructor; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; seat: right; restraint: 3-point; flight hours: 961 total, 211 in this make and model, 879 as pilot in command, 109 in the last 90 days, 45 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night - Wind: calm - Visibility: 10 statute miles - Temperature: 54 °F, dew point 43 °F - Altimeter: 30.03 inHg - Observed at: KPRB ## 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 20180306021779A](https://openairdocs.org/incident/20180306021779A), Mar 6, 2018: Piper PA-28R-200, Paso Robles, CA, Substantial damage. N33807 was on a training flight that originated in san jose California at the reid hillview airport (krhv) and terminated at the Paso roble municipal airport… ## Docket (5 files) The files NTSB released with the investigation on February 11, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96834. 5.7 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 566 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9073580&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Flight instructor statement (item 2, PDF, 2 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11938713&FileExtension=pdf&FileName=WPR18LA101%20Flight%20Instructor%20Statement-Rel.pdf - Student pilot statement (item 3, PDF, 1 page, 614 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11938818&FileExtension=pdf&FileName=WPR18LA101%20Student%20Statement-Rel.pdf - Maintenance records (item 4, PDF, 2 pages, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9072283&FileExtension=pdf&FileName=maintenance%20rec_Redacted-Rel.pdf - Photos (item 5, PDF, 3 pages, 216 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9073242&FileExtension=pdf&FileName=Photos-Rel.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.