# NTSB WPR23LA203: Piper PA-28-181, N456Y, West Jordan, UT, May 29, 2023 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: May 29, 2023, 11:52 local (17:52 UTC) - Place: West Jordan, UT - Coordinates: 40.609922, -111.99161 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.6099&lon=-111.9916&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: FAA-FSDO - NTSB case key (mKey): 192265 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR23LA203 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192265/pdf - Page: https://openairdocs.org/ntsb/WPR23LA203 ## Probable cause Loss of engine power due to fuel starvation as a result of the mechanic’s failure to properly secure the fuel system gascolator strainer bowl. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel filter-strainer](https://openairdocs.org/ntsb-findings/01022821): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-28-181, 2 cases](https://openairdocs.org/ntsb-findings/01022821/cases.md?model=7102807), [All aircraft, 52 cases](https://openairdocs.org/ntsb-findings/01022821/cases.md) - [Maintenance](https://openairdocs.org/ntsb-findings/02062000): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-findings/02062000/cases.md?model=7102807), [All aircraft, 143 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330); cases with it: [Piper PA-28-181, 4 cases](https://openairdocs.org/ntsb-events/330/sequence.md?model=7102807), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) - [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Piper PA-28-181, 8 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=7102807), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Landing-landing roll: Ground collision](https://openairdocs.org/ntsb-events/200); cases with it: [Piper PA-28-181, 16 cases](https://openairdocs.org/ntsb-events/200/sequence.md?model=7102807), [All aircraft, 618 cases](https://openairdocs.org/ntsb-events/200/sequence.md) ## Analysis The flight instructor was conducting a local flight in preparation for the student pilot’s private pilot check ride. The preflight was completed and both wing fuel tanks were filled. The engine was started, and no anomalies were noted during the startup, taxi or runup. During takeoff, the ground roll and departure were normal until the airplane reached about 300 ft above ground level (agl) when the engine started to lose power. The flight instructor took control of the airplane and added full rich mixture and ensured that the throttle lever was at full power. Momentarily, there was increase in rpm before the engine lost all power. He executed a forced landing that caused the landing gear to collapse and damaged the right wing, which resulted in the fuel tank leaking onsite. The postaccident examination revealed that the gascolator bowl bail wire attachment end was not engaged in the outboard attachment hole on the gascolator housing and was resting on the gascolator bracket forward of the hole. There was no observable impact damage to the gascolator or the surrounding area. The gascolator bowl was not sealed to the gascolator housing and was twisted inboard where the bowl’s sump was pointing forward, instead of its normal position pointing outboard towards the cowling sump access hole. The interior surfaces of both upper and lower cowling were covered in a light residue of oil with the exception of the cowling and firewall area beneath the gascolator. The lower engine cowling was removed. The bail wire was not safety wired in place, and the strainer bowl retaining nut was safety wired to the gascolator sump fitting. The strainer bowl retaining nut was not properly positioned on the bottom of the bowl. The gascolator bowl was removed and the seal and screen were undamaged and clear of contamination. The gascolator bowl did not contain any fuel. The gascolator bail wire was not properly attached to the housing and the gascolator bowl likely became unsealed, interrupting the fuel supply to the engine and causing the loss of engine power. ## Factual narrative On May 29, 2023, about 1152 mountain daylight time, a Piper PA-28-181, N456Y, was substantially damaged when it was involved in an accident near West Jordan, Utah. The flight instructor and student pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that the local flight from South Valley Regional Airport (U42), Salt Lake City, Utah, was in preparation for the student pilot’s private pilot check ride. He reported that earlier in the morning the aircraft fuel strainer and wing tanks were sumped and were clear of contaminants. A few hours later the airplane was refueled for the accident flight and the airplane was sumped once more. The fuel strainer was clear of contaminants and the right wing had several drops of water visible in the sump tool. The left tank had a significant amount of water visible in the sump tool. The preflight was completed and the engine was started; no anomalies were noted during the startup, taxi, or runup. The flight instructor reported that they departed with the fuel selector on the left-wing tank position. During takeoff, the ground roll was normal, and the airplane departed about 2,000 ft down the runway. About 300 ft agl, the engine started to lose power. The flight instructor took control of the airplane and added full rich mixture and ensured that the throttle lever was at full power. Momentarily, there was an increase in rpm before they lost all engine power. He initiated a forced landing to a soccer field complex about 1/4 mile south of U42. During the landing, the right main landing gear collapsed, and the airplane veered to the right impacting a tree with its right wing. The right wing fuel tank had impact damage and was leaking fuel onsite. Shortly after the accident, the airplane’s wing tanks were defueled from the filler ports, and the airplane was relocated to the airport. About 15 gallons of fuel was collected from the wing tanks. The gascolator and wing tanks were not sumped after the accident or during its relocation back to the airport. A postaccident examination of the wreckage revealed that the gascolator bowl bail wire attachment end was not engaged with the outboard attachment hole on the gascolator housing and was resting on the gascolator bracket forward of the hole, as shown in figure 1. There was no observable impact damage to the gascolator or the surrounding area. The gascolator bowl was not sealed to the gascolator housing and was twisted inboard where the bowl’s sump was pointing forward, instead of its normal position pointing outboard toward the cowling sump access hole. The interior surfaces of both upper and lower cowling were covered in a light residue of oil with the exception of the cowling and firewall area beneath the gascolator. Figure 1-Gascolator as seen from above. Figure 2-Gascolator forward side view, lower cowling removed. The lower engine cowling was removed. The bail wirewas not safety wired in place, and the strainer bowl retaining nut was safety wired to the gascolator sump fitting. The strainer bowl retaining nut was not properly positioned on the bottom of the bowl. The gascolator bowl was removed and the seal and screen were undamaged and clear of contamination. The gascolator bowl did not contain any fuel. Review of the maintenance records showed that the last 100-hour inspection was completed on April 1, 2023, about two months before the accident. The airplane had about 3,828 hours of operation at the time of the last inspection and had about 60 hours of operation since that inspection. Both Piper Service Letter 1141, dated April 11, 2011, and the Piper Maintenance Manual provide instructions to maintain and install the gascolator. The instructions direct the installer to safety bail nut and bail wire with MS20995-C32 safety wire, as shown in figure 2. They direct the installer to use the “double twist” method, as described in the latest revision of FAA Advisory Circular (AC) 43.13-1, Chapter 7 (Aircraft Hardware, Control Cables, and Turnbuckles), Section 7 (Safetying). Figure 3-Excerpt from the Piper Maintenance Manual. ## Aircraft - Registration: [N456Y](https://openairdocs.org/aircraft/N456Y), registered now, S/N 2843353, built 2000 (OpenAirDocs) - Reported make and model: PIPER PA-28-181 - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2843353 - Year built: 2000 - Airframe hours: 3889 - Engines: LYCOMING O&VO-360 SER 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Registered owner: Cavorite Aviation LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, April 1, 2023, 60.9 hours before - Airport: U42, South Valley Regional Airport, runway 16, 5,862 × 100 ft, asphalt - Equipment: Stall warning system, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 23; injuries: none; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review October 1, 2021; seat: right; restraint: 3-point; flight hours: 1,200 total, 1,160 in this make and model, 1,000 as pilot in command, 100 in the last 90 days, 40 in the last 30 days, 0 in the last 24 hours - Student pilot; age 37; injuries: none; student; medical: class 1, without waivers/limitations; seat: left; restraint: 3-point; flight hours: 60 total ## Weather - Conditions: Visual (VMC), Day - Wind: 140° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 43 °F - Altimeter: 30.02 inHg - Icing: Unknown - Turbulence: Unknown - Observed at: KU42, 1 nm away - METAR: KU42 291635Z AUTO 14009KT 10SM CLR 21/06 A3002 RMK AO1 T02050063 ## 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 20230529007189A](https://openairdocs.org/incident/20230529007189A), May 29, 2023: Piper PA-28-181, West Jordan, UT, Substantial damage. The pilot stated that shortly after takeoff and while in climb the engine began to lose some power, and shortly thereafter lost all power. The pilot selected… 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.