Pilot Debrief

PIPER PA28-200 near Jonesboro, AR — 2015-06-10

Final reportCEN15LA270
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Date
2015-06-10
Location
Jonesboro, AR, USA
Airport
JBR
Aircraft
PIPER PA28-200
Registration
N872CS
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Climb

Probable cause

Maintenance personnel's improper engine oil drain valve installation, which led to engine oil exhaustion and the subsequent loss of engine power after takeoff at an altitude too low for the pilot to execute a forced landing in a suitable area.

NTSB narrative

The private pilot was taking off for a personal flight. The pilot reported that, about 3 to 5 minutes after takeoff, the oil light illuminated and that, shortly thereafter, while the airplane was about 1,800 ft mean sea level, the oil pressure gauge indicated 0. About 20 to 30 seconds later, a total loss of engine power occurred. The pilot attempted to return to the departure airport but was unable to reach the runway due to insufficient altitude. The pilot subsequently conducted a forced landing in a parking lot, during which the airplane impacted a sign pole. Examination of the airplane revealed that, during retraction, the nose landing gear (NLG) had contacted and broken the engine oil drain valve, which was the incorrect part number. The airplane manufacturer had previously issued a service letter, which noted that, when the wrong part number drain valve was installed, it was possible that during NLG retraction the valve may contact the NLG drag link, become actuated, and allow the oil to be drained out in flight. The accident flight was the first flight since the drain valve had been replaced the previous day during a 100-hour/annual inspection. Given the evidence, maintenance personnel did not install the correct part number drain valve during the inspection, which resulted in it contacting the NLG and breaking. The oil then drained from the broken valve, which resulted in oil exhaustion and the subsequent loss of engine power.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have checked oil levels more thoroughly before takeoff.

NTSB coding

Evidence available

  • 4 docket documents
View NTSB final reportView NTSB docket

Docket documents4

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