WPR19LA065

NTSB accident investigation · Piper PA28 · Salt Lake City, UT · January 15, 2019

Accident · No injuriesClass 3 · LimitedFinal report
Date
January 15, 2019, 10:50 local (17:50 UTC)
Place
Salt Lake City, UT
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N1697JPiper PA28
Defining event
Approach-VFR pattern final: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
FAA FSDO
FAA report
20190115000219A
Case key
98837

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

A partial loss of engine power due to the mechanic’s failure to properly secure the throttle lever locking nut and cotter pin.

Findings · 2

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 · Incorrect service/maintenancePiper PA-28-140: 7 casesAll aircraft: 195 casesProbable cause
Misc hardware: fastenersAircraft › Fluids/misc hardware · Incorrect service/maintenancePiper PA-28-140: 1 caseAll aircraft: 58 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 was practicing takeoffs and landings when the engine became unresponsive to throttle inputs. He performed a forced landing onto a highway, during which the airplane was substantially damaged. Examination of the engine revealed that the carburetor throttle lever lock nut was finger-tight, and its cotter pin was absent, which likely resulted in the throttle lever intermittently disengaging from the serrated throttle shaft when the pilot manipulated the throttle. A review of the maintenance log books and an interview with the mechanic revealed that the throttle cable had been removed and subsequently reinstalled onto the carburetor as part of the most recent annual inspection, which was completed about 1 month before the accident. It is likely that, at this time, the mechanic did not install or inadequately installed the cotter pin through the locking nut and bolt.

Factual narrative

On January 15, 2019, about 1050 mountain standard time, a Piper PA28-140 airplane, N1697J, was substantially damaged when it was involved in an accident near Salt Lake City, Utah. The commercial pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he was practicing touch-and-go landings. While on landing approach, he reduced the throttle control to decrease engine rpm; however, the engine remained at 2,200 rpm. He then pushed the throttle back in and the power increased to 2,500 rpm. He attempted to reduce throttle again, but the engine remained at 2,500 rpm. The pilot initiated a go-around, and, shortly thereafter, engine power decreased from 2,500 to 1,500 rpm. With no usable runway remaining, the pilot performed a forced landing to a road, during which the propeller struck the road and the landing gear sheared off the airplane. The service manual for the Marvel-Schebler Model MA4 series carburetor lists a castellated nut and cotter pin to secure the serrated throttle arm to the throttle shaft of the carburetor (see figure 1). Examination of the engine revealed that the carburetor serrated throttle lever locking nut was finger-tight and the cotter pin was absent. When the throttle lever was retracted and extended, the loosely attached throttle shaft did not move, as shown in figures 2 and 3. Figure 1. Excerpt from the Marvel-Schebler Carburetor Service Manual. A review of the engine maintenance records revealed that, on December 14, 2018, as part of the annual inspection, the mechanic wrote, "Verified control movement and lubricated." In an interview with a Federal Aviation Administration (FAA) representative, the mechanic confirmed that he took the throttle cable off to do this work. Postaccident examination of the carburetor at Precision Air Power, Woods Cross, Utah revealed no anomalies that would have precluded normal operation. Figure 2. Note the serrated throttle lever and idle stop at the idle position. Figure 3. Photo showing the serrated throttle lever at full power setting while the idle stop lever remained at idle.

Aircraft

Registration
N1697J
Reported as
Piper PA28 (140)
Category
Airplane
Serial number
28-24103
Built
1968
Airframe hours
3,661.93
Engine
Lycoming O-320 SERIES, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 14, 2018
Departed
U42 · Salt Lake City, UT
Destination
U42 · Salt Lake City, UT
Airport
U42 · South Valley Regional Airport, runway 16, 5,808 × 100 ft, asphalt
Equipment
Handheld GPS

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
42
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 1, With waivers/limitations
Seat
Left
Flight hours
3,859 total · 11 in this make and model · 3,753 as pilot in command · 158 in the last 90 days · 5 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 4 knots
Visibility
8 statute miles
Lowest ceiling
4,500 ft broken
Temperature
30 °F, dew point 21 °F
Altimeter
30.13 inHg
Observed at
KSLC, 115 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.