WPR19LA050

NTSB accident investigation · Piper PA28 · Santa Ana, CA · December 23, 2018

Accident · No injuriesClass 3 · LimitedFinal report
Date
December 22, 2018, 16:22 local (Dec 23, 2018, 00:22 UTC)
Place
Santa Ana, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N15321Piper PA28
Defining event
Initial climb: Fuel related
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration FSDO
FAA report
20181222023259A
Case key
98820

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

A total loss of engine power due to a loose carburetor bowl.

Findings · 1

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.

Engine fuel and control: fuel control/carburetorAircraft › Aircraft power plant · Damaged/degradedPiper PA-28-140: 7 casesAll aircraft: 195 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

Shortly after takeoff on the instructional flight, the engine lost total power. The flight instructor took the airplane controls and returned to the airport for a forced landing, during which the airplane landed hard on a taxiway, resulting in substantial damage. Postaccident examination revealed that the carburetor bowl was loose and displayed evidence of a fuel leak. The leak likely resulted in fuel flow irregularities and the loss of engine power. Although service bulletins had been published by both the carburetor and engine manufacturer to address this issue, there was no evidence to suggest that the accident airplane had undergone the inspections specified by the service bulletins.

Factual narrative

On December 22, 2018, about 1622 Pacific standard time, a Piper PA28-140, N15321, was substantially damaged when it was involved in an accident near Santa Ana, California. The flight instructor and student pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 instructional flight. The instructor stated that the student was flying the airplane during takeoff from runway 20L. After they reached about 250 ft above ground level, the engine lost total power. The instructor took the airplane controls and began to look for a landing site. He declared an emergency and initiated a return to the airport with the intention of landing on runway 2R. The instructor stated that, just before landing, the airplane encountered a strong wind shear, and they landed hard on an intersecting taxiway. The airplane sustained substantial damage to both wings and the forward fuselage. Evidence of 100 low-lead aviation gasoline was found in the fuel supply system. All fuel lines were intact at their respective fittings, and all filters and screens were free of debris. The engine’s internal drivetrain was intact and there was no evidence of catastrophic failure. Both magnetos produced sparks when tested. The spark plugs exhibited dark grey deposits and wear signatures consistent with a short service life. The throttle, mixture, and carburetor heat controls were intact, and their linkages were continuous through to their respective cabin controls. The airplane was equipped with an MA-4SPA carburetor. Removal and examination of the carburetor revealed that two of the four screws that mounted the carburetor bowl to the throttle body (aft, data tag side) were loose, and although lock-tab washers were installed, the screws could still be turned by hand, and the bowl could be moved. The bowl-to-body contact surface and corresponding area of the bowl gasket were dark in color, and evidence of fluid flow was present on the lower outer surfaces of the bowl. Maintenance records indicated that the engine was last overhauled in August 2011, about 1,568 flight hours before the accident. The records indicated that the carburetor had been overhauled at that time, and there were no entries indicating any work had been performed on the carburetor in the 7 years leading up to the accident. The last documented maintenance inspection event was an annual inspection on December 19, 2017, 42.2 flight hours before the accident. Service Bulletin SB-17 dated August 12, 2010, issued by Marvel-Schebler Aircraft Carburetors, LLC., with a subject of, "Body to Bowl Fuel Leaks," directed an inspection of the carburetor every 100 hours of engine operation. The bulletin described reports of loose body-to-bowl joints, with resulting leakage past the body-to-bowl gasket. Compliance required a visual inspection of the carburetor for evidence of movement, with remedial repairs should such evidence be found. Lycoming Mandatory Service Bulletin SB 366C, datedJune 2, 2016, also directed a similar inspection of the carburetor every 50 hours of engine operation. Maintenance records did not specifically state that SB-17 or SB 366C had ever been performed; however, compliance with service bulletins is not mandatory for aircraft operated under 14 CFR Part 91.

Aircraft

Registration
N15321
Reported as
Piper PA28 (140)
Category
Airplane
Serial number
28-7325039
Built
1972
Airframe hours
13,795
Engine
Lycoming O-320-E3D, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
TRC Holdings, doing business as TRC Aviation Academy
Registered owner
TRC Holdings
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · December 19, 2017 · 42.2 hours before
Departed
KSNA · Santa Ana, CA
Destination
KSNA · Santa Ana, CA
Airport
KSNA · John Wayne Airport, runway 2R, 2,887 × 75 ft, asphalt
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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
45
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
March 25, 2018
Seat
Right
Restraint
3-point
Flight hours
770 total · 425 in this make and model · 620 as pilot in command · 29 in the last 90 days · 13 in the last 30 days · 1 in the last 24 hours
Role
Student pilot
Age
16
Injuries
None
Certificate
Student
Medical
Class 3, Without waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
23 total · 10 in this make and model · 14 in the last 90 days · 10 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 5 knots
Visibility
5 statute miles
Lowest ceiling
25,000 ft broken
Temperature
63 °F, dew point 54 °F
Altimeter
30.04 inHg
Observed at
KSNA, 1 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.