Pilot Debrief

Piper PA28R near Prairieville, LA — 2019-04-03

Final reportCEN19LA132
Sign in to save
Date
2019-04-03
Location
Prairieville, LA, USA
Aircraft
Piper PA28R
Registration
N41AT
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Initial climb

Probable cause

Installation of an incorrect engine oil drain valve, which resulted in damage to the valve during landing gear retraction and subsequent engine failure due to oil starvation. Contributing to the accident was the failure of maintenance personnel to comply with the Airworthiness Directive regarding the engine oil drain valve.

NTSB narrative

The pilot was conducting the airplane's first flight following an annual inspection. About 5 minutes after takeoff, the engine started to run rough and seized. The pilot performed a forced landing, during which he sustained serious injuries. Postaccident examination revealed that the engine oil drain valve was damaged when the nose landing gear contacted the valve during gear retraction after takeoff. This resulted in a loss of engine oil and subsequent engine failure due to oil starvation. Further examination revealed that the installed drain valve did not meet manufacturer specifications; the installed valve protruded about 1-1/8 inches from the engine, while the manufacturer-specified valve protruded about 1/2 inch. A review of the airplane maintenance records revealed that the valve was replaced during the annual inspection because it had been leaking. The airframe manufacturer had previously issued a service bulletin regarding installation of an incorrect engine oil drain valve. The Federal Aviation Administration subsequently issued an Airworthiness Directive requiring the replacement of any incorrectly installed valves and placement of a warning placard on the engine mount. The airplane maintenance manual also included a cautionary note regarding the engine oil drain valve and noted the requirement for a warning placard. A warning placard was not present on the accident airplane.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Inspection of the oil drain valve before the flight could have prevented the accident.

NTSB coding

Evidence available

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

Docket documents10

Related mishaps