Pilot Debrief

PIPER PA 28RT-201 near Russell Springs, KY — 2015-09-04

Final reportERA15LA341
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Date
2015-09-04
Location
Russell Springs, KY, USA
Airport
K24
Aircraft
PIPER PA 28RT-201
Registration
N8162S
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Approach

Probable cause

Maintenance personnel’s inadequate fuel injection servo maintenance due to an out-of-date AD list, which resulted in the fuel injection servo plug backing out of the threaded plug hole on the regulator cover of the fuel injection servo and subsequent total loss of engine power.

NTSB narrative

While the airline transport pilot was flying a practice instrument approach in visual meteorological conditions, the airplane incurred a total loss of engine power. During the forced landing, the fuselage and wings were substantially damaged. Postaccident examination of the engine revealed that the brass fuel injection servo plug had backed out of the threaded plug hole on the regulator cover of the fuel injection servo and was hanging below the fuel servo by a piece of safety wire. The missing plug likely resulted in the engine running excessively lean and losing power. In the 7 years between the manufacturer’s discovery that the fuel injection servo plug could back out of the regulator cover hole, and the accident, the manufacturer had published a safety alert, a mandatory service bulletin, and two service information letters (SILs) advising of the issue and recommending corrective actions to prevent a loss of engine power, all of which were applicable to the accident airplane. The Federal Aviation Administration had also published three airworthiness directives (ADs) mandating the specified changes developed by the manufacturer. Review of the maintenance records for the airplane and engine revealed no entries that indicated when the fuel injection servo had been last overhauled; if any of the actions published in the safety alert, mandatory service bulletin, SILs had been accomplished; or if any maintenance had occurred that would have required removal and reinstallation of the plug. Further review of the maintenance records also indicated that the mechanic who had been maintaining the airplane for about 10 years used a service provider to provide him with ADs; however, the AD list was not current, and none of the three ADs were included in the published AD list. Thus, the ADs had not been accomplished for the airplane.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Inspect fuel injection servo for hex plug issues before flight.

NTSB coding

Evidence available

  • Photos
  • 11 docket documents
View NTSB final reportView NTSB docket

Docket documents11

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