Pilot Debrief

PIPER PA-28R-200 near Slaughters, KY — 2023-03-02

Final reportERA23LA144
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Date
2023-03-02
Location
Slaughters, KY, USA
Aircraft
PIPER PA-28R-200
Registration
N9420N
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Climb

Probable cause

Maintenance personnel’s failure to secure the fuel strainer bowl with safety wire, which resulted in the fuel strainer bowl leaking and starving the engine of fuel. Also causal was the obstruction of two fuel injector nozzles.

NTSB narrative

The pilot purchased an airplane that had not flown in 22 years and that had an extensive annual inspection completed the day before the accident flight. On the day of the accident, the pilot flew the airplane on a short flight to an airport and topped off the fuel tanks. About 5 minutes after he departed on the second leg, the engine started to lose power so he performed an off-airport forced landing. The airplane landed hard, which resulted in substantial damage to the wings. Postaccident examination of the airplane revealed that when electrical power was applied to the electric fuel pump, fuel leaked from the fuel strainer bowl. Further examination of the fuel strainer bowl revealed that the thumb wheel, which secured the fuel strainer bowl to the firewall, was loose and not secured with safety wire. Examination of the fuel system forward of the fuel strainer bowl revealed no fuel was present up to the fuel nozzles. Once the fuel strainer bowl was secured and the thumb wheel tightened, fuel flowed to the fuel nozzles and no leaks were noted. Additionally, one of the fuel injector nozzles was completely obstructed and another was partially obstructed. Since the fuel bowl was not safety wired, it likely loosened from vibration after the annual inspection which resulted in fuel leaking from the fuel strainer bowl. The fuel leak likely starved the engine of adequate fuel to operate normally, and contributed to the partial loss of engine power. The obstructed fuel injector nozzles also likely negatively impacted the engine’s performance during the flight.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Ensure fuel system integrity before flight to prevent power loss.

NTSB coding

Evidence available

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

Docket documents8

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