Pilot Debrief

PIPER PA 32R-300 near Dawsonville, GA — 2017-10-30

Final reportANC18LA006
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Date
2017-10-30
Location
Dawsonville, GA, USA
Aircraft
PIPER PA 32R-300
Registration
N4213F
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Climb

Probable cause

The failure of the pilot, who was not a certified mechanic, to tighten the B-nut on a remotely mounted oil filter line, which resulted in oil exhaustion, a total loss of oil pressure, and a subsequent total loss of engine power.

NTSB narrative

The private pilot was conducting a personal flight and reported that, while the airplane was climbing after takeoff, the engine began to run roughly and lose power. The pilot began a descent for an emergency landing and, during the descent, he sensed a "bad" engine vibration, which was followed by a complete loss of engine power. The pilot selected an area on an asphalt-covered automobile racetrack to make a forced landing, which resulted in substantial damage to the airplane's wings and fuselage. A postaccident engine examination revealed a crack in the accessory case and a large hole in the crankcase near the No. 6 cylinder pad. A subsequent internal examination revealed damage to the engine's internal components, including the main bearings and the No. 6 connecting rod, that was consistent with oil exhaustion. The airplane was equipped with a remotely mounted oil filter. A B-nut on one of the oil filter lines was found to be loose with about 2 ½ threads showing. The B-nut was tightened by hand and rotated about 1 ¾ turns, which resulted in about ½ thread showing. The pilot stated that he was not an airframe and powerplant mechanic but that he had replaced the oil line about 1 week before the accident. The accident flight was the first flight after that maintenance.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot could have checked oil line installation before flight.

NTSB coding

Evidence available

  • ATC audio
  • Video
  • Photos
  • 5 docket documents
View NTSB final reportView NTSB docket

Docket documents5

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