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NTSB Report

July 31, 1997 · Piper PA-28R-180 · N4667J

Buckeye, AZ

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
July 31, 1997
Injury Outcomes
2 injuries (2 minor injuries)
Location
Buckeye, AZ
Aircraft
Piper PA-28R-180
Tail Number
N4667J
Injuries
Minor
Aircraft Damage
Substantial
NTSB Number
LAX97LA266

The owner of the airplane, who is a certified A & P mechanic, had complied with an AD which required the replacement of the oil cooler hose. He ran the engine up to idle but did not remove the engine cowling to check for signs of an oil leak. The airport manager stated he noticed a large oil puddle at the site where the airplane was started and a trail of oil leading out to the runway. The airplane climbed about 250 feet when the engine quit and a forced landing was made. The engine teardown revealed no oil in the engine, with heat distress noted to the bearings and journals, and the number 2 connecting rod separated from the crankshaft. One oil cooler line was loose and required an 180-degree turn to tighten the nut.

NTSB Probable Cause

The total oil exhaustion of the engine due to the inadequate maintenance installation of the oil cooler lines by the owner/mechanic.

Full Narrative

On July 31, 1997, at 0814 hours mountain standard time, a Piper PA-28R-180, N4667J, collided with a dirt berm in a cotton field and nosed over following a forced landing near Buckeye, Arizona. The forced landing was precipitated by a total loss of engine power while the aircraft was climbing to a cruise altitude. The airplane sustained substantial damage. The private pilot who was in the left seat, and the owner, who was also a private pilot and in the right seat, sustained minor injuries. The airplane was operated as a personal flight under 14 CFR Part 91 when the accident occurred. The flight originated in Buckeye, and visual meteorological conditions prevailed at the time of the accident. The owner of the airplane holds an FAA Airframe and Powerplant mechanic certificate, and performs the maintenance on the aircraft. Review of the maintenance records and an interview with the owner revealed that he had complied with AD 95-26-13, which required the replacement of the oil cooler hoses. This maintenance was performed on July 25, 1997. The owner said he replaced two oil cooler lines, then subsequently ran up the engine to idle, but did not remove the engine cowling to check for signs of an oil leak. According to Lycoming, the reported idle run/leak check was "most likely of a duration not sufficient to produce enough heat to activate the oil cooler by-pass valve, thus diverting the engine oil around the oil cooler. It is unlikely that a leak would have been detected until the engine obtained normal operating temperature." The airport manager noticed a large amount of oil from where the airplane was run up leading out to the runway for quite some distance. The engine was torn down on August 7, 1997, at Air Transport, Phoenix, Arizona under the supervision of the Safety Board and a complete report of the examination is appended to this report. No lubricating oil was found within the engine. The engine was seized and the crankshaft would not rotate. Heat distress was observed to the internal bearings and journals, with the number 2 connecting rod separated from the crankshaft. The remaining engine rotating group components and valve train were examined further with no evidence of any other mechanical malfunction observed. The Lycoming engine representative noted that the "B" nut of the oil cooler line that attaches to the engine accessory case above the left magneto was loose and required an 180-degree turn to tighten. The owner of the aircraft said that as the aircraft was descending he had to manually hold the emergency landing gear extension lever in the "override" position in order to keep the landing gear from extending. He told investigators that as the aircraft was about to land in the cotton field, he "let go of the lever in order to brace himself." The landing gear immediately extended. As the aircraft touched down in the field, it nosed over onto its back. According to the Piper Aircraft Corporation representative on scene, the examination of the accident airplane revealed that the emergency landing gear override system had no lockout mechanism installed. On October 19, 1983, Piper Aircraft issued Service Bulletin No. 769 which recommended that aircraft equipped with back-up landing gear extension systems install a lockout mechanism. On March 4, 1988, Piper Aircraft issued Service Bulletin No. 866A allowing operators of aircraft equipped with back-up landing gear extension systems to either remove the system or review and understand all the information contained in the applicable airplane Flight Manual/Pilot's Operating Handbook pertaining to the normal and emergency operation of the system. Service Bulletin No. 866A requires aircraft affected by Service Bulletin No. 769 to comply with that bulletin prior to or concurrent with compliance with Service Bulletin No. 866A. Piper Aircraft considers compliance with Service Bulletin No. 866A mandatory.

Flight

Event TypeAccident
Event Time08:14 MST
Nearest AirportBuckeye Muni (2nm SSW)
Runway0
Flight Plan FiledNone
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftPiper PA-28R-180
Tail NumberN4667J
Aircraft CategoryAir
DamageSubstantial
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsLycoming · IO-360-B1E · Reciprocating · 180
Seats4

People & Injuries

Injury Summary2 injuries (2 minor injuries)
Fatal0
Serious0
Minor2
Uninjured0
Total2
Crew 1Age 64 · Third Class

Conditions

ConditionsVMC
LightDaylight
WindCalm
Visibility50 sm
CeilingNone
Temperature / Dew Point10 C / 50
Altimeter29.00 inHg
Observation Time14:50
Weather SourceWFAC

Appendix: Source Data