# NTSB WPR24LA267: Piper PA-28R-201T, N135DG, Sacramento, CA, August 4, 2024 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: August 4, 2024, 13:15 local (20:15 UTC) - Place: Sacramento, CA · golf course - Coordinates: 38.633463, -121.40314 - Nearby events: https://openairdocs.org/map.md?lat=38.6335&lon=-121.4031&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report June 10, 2026 - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 194852 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR24LA267 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/194852/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=194852 - Page: https://openairdocs.org/ntsb/WPR24LA267 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Maintenance personnel (probable cause); cases with it: [Piper PA-28R-201T, 2 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=7102813), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Turbocharging (recip only): turbocharger](https://openairdocs.org/ntsb-findings/01058120): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Piper PA-28R-201T, 1 case](https://openairdocs.org/ntsb-findings/01058120/cases.md?model=7102813), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/01058120/cases.md) - [Turbocharging (recip only)](https://openairdocs.org/ntsb-findings/01058100): Aircraft › Aircraft power plant · Malfunction (probable cause); cases with it: [Piper PA-28R-201T, 1 case](https://openairdocs.org/ntsb-findings/01058100/cases.md?model=7102813), [All aircraft, 6 cases](https://openairdocs.org/ntsb-findings/01058100/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Piper PA-28R-201T, 1 case](https://openairdocs.org/ntsb-events/340/sequence.md?model=7102813), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) ## 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](https://openairdocs.org/aircraft/N135DG), registered now, S/N 28R-7803122, built 1977 (OpenAirDocs) - Reported make and model: PIPER PA-28R-201T - Registry model: [Piper PA-28R-201T](https://openairdocs.org/model/piper-pa-28r-201t) (registry code 7102813) (OpenAirDocs) - Registry engine: [Continental TSIO-360 series](https://openairdocs.org/engine/continental-tsio-360-series) (registry code 17019, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7803122 - Year built: 1977 - Airframe hours: 4026.3 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 34; injuries: minor; 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= ## 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 20240804022309A](https://openairdocs.org/incident/20240804022309A), Aug 4, 2024: Piper PA-28R-201T, Sacramento, CA, Destroyed. Pilot landed at mcc with approximately ½ tanks, filled both tanks at mcclellan. Completed full run up prior to take off. Kept the fuel on the same tank. Engine… ## Docket (10 files) The files NTSB released with the investigation on June 10, 2026, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=194852. 16.7 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 5.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17603783&FileExtension=pdf&FileName=6120%20267_Redacted-Rel.pdf - Ipc excerpt (item 2, PDF, 4 pages, 6.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20360144&FileExtension=pdf&FileName=Continental%20IPC%20Excerpt-Rel.pdf - Troubleshooting excerpt (item 3, PDF, 1 page, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20360100&FileExtension=pdf&FileName=Piper%20Powerplant%20Troubleshooting%20Table-Rel.pdf - Component exemplar (item 4, PDF, 4 pages, 486 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20360090&FileExtension=pdf&FileName=MS21920-26%20T-bolt%20clamp%20exemplar-Rel.pdf - Follow-up examination summary (item 5, PDF, 10 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20360767&FileExtension=pdf&FileName=WPR24LA267%20Follow%20Up%20Exam%20Summary-Rel.pdf - Investigation photos (item 6, PDF, 6 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20360665&FileExtension=pdf&FileName=Accident%20Photos-Rel.pdf - Edm download summary report (item 7, PDF, 3 pages, 380 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20361250&FileExtension=pdf&FileName=WPR24LA267%20EDM%20Exam%20Report-Rel.pdf - Device download (item 8, CSV, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20360442&FileExtension=csv&FileName=Flt199-last%20cycle-Rel.csv - Release of aircraft wreckage, NTSB form 6120.15 (item 9, PDF, 2 pages, 161 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20359784&FileExtension=pdf&FileName=NTSB%20WRECKAGE%20RELEASE_Redacted-Rel.pdf - Evidence control form (item 10, PDF, 2 pages, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20360432&FileExtension=pdf&FileName=Evidence%20Control%20Form%20267-Rel.pdf 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.