WPR24LA267

NTSB accident investigation · Piper PA-28R-201T · Sacramento, CA · August 4, 2024

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
August 4, 2024, 13:15 local (20:15 UTC)
Place
Sacramento, CA · golf course
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N135DGPiper PA-28R-201T
Defining event
Initial climb: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report June 10, 2026
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20240804022309A
Case key
194852

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 loss of engine power during the initial climb due to the detachment of the turbocharger’s inlet sleeve as a result of the installation of an incorrect sleeve clamp.

Findings · 3

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.

Action: incorrect action performancePersonnel issues › Action/decision · Maintenance personnelPiper PA-28R-201T: 2 casesAll aircraft: 1,386 casesProbable cause
Turbocharging (recip only): turbochargerAircraft › Aircraft power plant · Incorrect service/maintenancePiper PA-28R-201T: 1 caseAll aircraft: 29 casesProbable cause
Turbocharging (recip only)Aircraft › Aircraft power plant · MalfunctionPiper PA-28R-201T: 1 caseAll aircraft: 6 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 reported that, shortly after takeoff at an altitude about 500 ft, the engine sputtered, then lost total power. The pilot attempted to restore engine power while turning back to the departure airport. Realizing that he would not reach the airport, the pilot initiated a forced landing onto a golf course, during which the airplane impacted a building and sustained substantial damage. The engine data monitor revealed that the manifold pressure and rpm were 30.5 inches of mercury (inHg) and 2,339 rpm, respectively, when the pilot returned to the airport, about 1.6 nautical miles from the departure end of the runway at an altitude of 691 ft agl. The last recorded data was 29.3 inHg and 148 rpm, recorded at an altitude of 60 ft about 1,280 ft from the accident site. Postaccident examination revealed a disconnected sleeve connecting the air filter cover assembly to the turbocharger inlet. The airplane’s illustrated parts catalog showed that a T-bolt, flat-banded clamp was needed to secure the sleeve to the turbocharger inlet; however, the clamp that had been installed was a lined worm gear clamp. The turbocharger inlet sleeve was reattached with the existing worm gear clamp to facilitate a test run. During the test run, the engine ran for 5 minutes between 1,300 to 1,500 rpm due to impact damage, which precluded operating the engine at higher power settings or at idle. After the engine run, the inlet sleeve was again found disconnected. Review of the airplane’s maintenance logbooks indicated that the turbocharger was removed and reinstalled about 4 years before the accident flight; the entry did not contain information about the hardware used to reinstall the turbocharger. The airplane’s most recent annual inspection was conducted about 4 months and 38 flight hours before the accident flight.

Factual narrative

On August 4, 2024, about 1315 Pacific daylight time, a Piper PA-28R-201T airplane, N135DG, was substantially damaged when it was involved in an accident near Sacramento, California. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he refueled the airplane before departure. He subsequently completed a preflight inspection and engine runup, verifying that the fuel selector lever was set to the right wing fuel tank. During the takeoff roll, he confirmed that he had takeoff power set to 39 inches of manifold pressure. During the initial climb, about 500 ft mean sea level, the engine sputtered, and the pilot noticed that the manifold pressure indicated about 31 inches. The pilot initiated a 180° turn toward the airport, turned the fuel boost pump to the “high” position, and declared an emergency with the air traffic control tower. As he realized he would not be able to make it to the airport, the pilot initiated a forced landing on a nearby golf course. During the landing sequence, the airplane impacted the ground and subsequently slid into a building before it came to rest upright. Postaccident examination of the airplane revealed substantial damage to both wings. Data recovered from the onboard engine monitor revealed that the manifold pressure and rpm were 30.5 inches of mercury (inHg) and 2,339 rpm, respectively, when the pilot returned to the airport, about 1.6 nautical miles from the departure end of the runway at an altitude of 691 ft. The last recorded data was 29.3 inHg and 148 rpm, recorded at an altitude of 60 ft about 1,280 ft from the accident site. Examination of the airframe revealed that the sleeve connecting the air filter cover assembly to the turbocharger inlet had detached. A review of the airplane illustrated parts catalog showed that a t-bolt, flat-banded clamp, part number MS-21920-26, was required. Instead, a lined worm gear clamp was discovered around the sleeve that held it onto the inlet of the turbocharger. A t-bolt flat-banded clamp can provide consistent, 360°, leak-resistant sealing under high vibration and temperature, ideal for hose connections (see figure 1). Figure 1. View of turbocharger, installed clamps, and required T-banded clamp overlayed over an image of the engine from the IPC. The engine remained attached to the engine mounts and the damaged engine truss. Both propeller blades remained attached to the propeller hub and flange, which was connected to the crankshaft. The accessory case and attached accessories were unremarkable. An oil drain plug was replaced, and the turbocharger inlet sleeve was reinstalled with the two found worm gear clamps. After oil was added, the engine started using fuel drawn from a header tank that was plumbed into the fuel system and the engine was run at a constant 1,300 to 1,500 rpm for 5 minutes. Due to impact damage, the engine could not be operated at higher power settingsor at idle. The throttle, mixture, and propeller controls were not operating with full travel due to impact damage to the engine mounting. After shutdown, the sleeve was again found detached from the turbocharger. The engine logbook indicated that the most recent maintenance performed was an annual inspection completed on April 2, 2024, about four months before the accident flight. The entry for the inspection stated that the induction system was checked. On September 22, 2020, about four years before the accident, the turbocharger was reinstalled after it was repaired. The log entry did not specify whether the hardware securing the inlet sleeve was replaced. The logbook did not contain any additional references to the turbocharger between September 2020 and the accident flight.

Aircraft

Registration
N135DG
Reported as
Piper PA-28R-201T
Category
Airplane
Serial number
28R-7803122
Built
1977
Airframe hours
4,026.3
Engine
Continental TSIO-360-EcKBcFB, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Sg Solutions LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 2, 2024 · 38 hours before
Destination
KHAF · Half Moon Bay, CA
Airport
MCC · Mc Clellan Airfield, runway 16/34, 10,599 × 150 ft, concrete
Equipment
ADS-B, Auto-pilot, Data recorder

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
34
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
July 16, 2024
Seat
Left
Flight hours
130.1 total · 12.2 in this make and model · 19.9 as pilot in command · 42.6 in the last 90 days · 21.1 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Visibility
9 statute miles
Lowest ceiling
None
Temperature
91 °F, dew point 54 °F
Altimeter
29.85 inHg
Observed at
KMCC, 2 nm away
METAR
METAR KMCC 042015Z AUTO VRB05KT 10SM CLR 33/12 A2985 RMK AO2 PWINO=

Docket · 10

The files NTSB released with the investigation on June 10, 2026, on NTSB’s docket system: statements, records, photos and specialists’ reports. 16.7 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.