# NTSB WPR19LA050: Piper PA28, N15321, Santa Ana, CA, December 23, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: December 22, 2018, 16:22 local (Dec 23, 2018, 00:22 UTC) - Place: Santa Ana, CA - Coordinates: 33.675277, -117.86888 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.6753&lon=-117.8689&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration FSDO - NTSB case key (mKey): 98820 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19LA050 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98820/pdf - Page: https://openairdocs.org/ntsb/WPR19LA050 ## Probable cause A total loss of engine power due to a loose carburetor bowl. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine fuel and control: fuel control/carburetor](https://openairdocs.org/ntsb-findings/01057322): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [Piper PA-28-140, 7 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md?model=7102802), [All aircraft, 195 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Piper PA-28-140, 8 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=7102802), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Piper PA-28-140, 42 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102802), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing-flare/touchdown: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-140, 137 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102802), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N15321-2020-03-06), registration cancelled 2020-03-06, S/N 28-7325039, built 1972 (OpenAirDocs) - Reported make and model: Piper PA28 (140) - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming O&GO-145C series](https://openairdocs.org/engine/lycoming-o-go-145c-series) (registry code 41503, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7325039 - Year built: 1972 - Airframe hours: 13795 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 45; injuries: none; 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 - Student pilot; age 16; injuries: none; 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 (OpenAirDocs). - [Accident 20181222023259A](https://openairdocs.org/incident/20181222023259A), Dec 22, 2018: Piper PA-28-140, Santa Ana, CA, Substantial damage. John Wayne airport (ksna): N15321, PA-28-140, departed runway 20R, experienced a rough engine which quit about 500 feet. Aircraft returned and landed on… 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.