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January 2, 1993 · Piper PA-28R-201T PA-28R-201 · N2008M

Concord, CA

Overview

Report Status
Probable Cause
Event Type
Accident
Date
January 2, 1993
Injury Outcomes
1 injury (1 minor injury)
Location
Concord, CA
Aircraft
Piper PA-28R-201T PA-28R-201
Tail Number
N2008M
Operator
Richard Talley/Larry Shattuck
Injuries
Minor
Aircraft Damage
Substantial
NTSB Number
LAX93LA088

During an IFR flight at about 11,000 feet MSL, the airplane's engine began to run rough and the engine oil pressure dropped to zero. The pilot also said he smelled something that was burning. The pilot entered a descent and requested vectors to the nearest airport. While on the vector, the engine began to run rougher and the burning smell became stronger. The pilot shut down the engine and entered a power off forced landing. He broke out of the clouds and determined that he could not glide to the airport. He performed a landing to the only available area. During touchdown, the airplane collided with posts. An FAA safety inspector examined the engine. He determined that 1 of the 4 bolts used to bolt the engine oil pump cover to the crankcase was missing. A damaged bolt was found in the engine's camshaft gear. The tab washers used to lock the oil pump cover bolts had their single tab bent downward. The tab washers' twin tabs on the 3 remaining bolts were pointed straight out. They appeared to have never been bent into place after the bolts were tightened. Improper installation of the washers resulted in one bolt falling off and being ingested through various drive gears. The engine was overhauled by the manufacturer 515 hours prior to the accident.

NTSB Probable Cause

THE ENGINE MANUFACTURER FAILING TO PROPERLY INSTALL TAB WASHERS DURING OVERHAUL WHICH RESULTED IN ONE BOLT BECOMING LOOSE AND BEING INGESTED THROUGH VARIOUS ENGINE GEAR DRIVES. THE INGESTION AND LOOSE OIL PUMP COVER RESULTED IN THE ENGINE RUNNING ROUGH AND A BURNING SMELL WHICH CAUSED THE PILOT TO HAVE TO SHUT DOWN THE ENGINE.

Full Narrative

DURING AN IFR FLIGHT AT ABOUT 11,000 FEET MSL, THE AIRPLANE'S ENGINE BEGAN TO RUN ROUGH AND THE ENGINE OIL PRESSURE DROPPED TO ZERO. THE PILOT ALSO SAID HE SMELLED SOMETHING THAT WAS BURNING. THE PILOT ENTERED A DESCENT AND REQUESTED VECTORS TO THE NEAREST AIRPORT. WHILE ON THE VECTOR, THE ENGINE BEGAN TO RUN ROUGHER AND THE BURNING SMELL BECAME STRONGER. THE PILOT SHUT DOWN THE ENGINE AND ENTERED A POWER OFF FORCED LANDING. HE BROKE OUT OF THE CLOUDS AND DETERMINED THAT HE COULD NOT GLIDE TO THE AIRPORT. HE PERFORMED A LANDING TO THE ONLY AVAILABLE AREA. DURING TOUCHDOWN, THE AIRPLANE COLLIDED WITH POSTS. AN FAA SAFETY INSPECTOR EXAMINED THE ENGINE. HE DETERMINED THAT 1 OF THE 4 BOLTS USED TO BOLT THE ENGINE OIL PUMP COVER TO THE CRANKCASE WAS MISSING. A DAMAGED BOLT WAS FOUND IN THE ENGINE'S CAMSHAFT GEAR. THE TAB WASHERS USED TO LOCK THE OIL PUMP COVER BOLTS HAD THEIR SINGLE TAB BENT DOWNWARD. THE TAB WASHERS' TWIN TABS ON THE 3 REMAINING BOLTS WERE POINTED STRAIGHT OUT. THEY APPEARED TO HAVE NEVER BEEN BENT INTO PLACE AFTER THE BOLTS WERE TIGHTENED. IMPROPER INSTALLATION OF THE WASHERS RESULTED IN ONE BOLT FALLING OFF AND BEING INGESTED THROUGH VARIOUS DRIVE GEARS. THE ENGINE WAS OVERHAULED BY THE MANUFACTURER 515 HOURS PRIOR TO THE ACCIDENT.

Flight

Event TypeAccident
Event Time13:45 PST
Nearest Airport0nm N
Runway0
Flight Plan FiledIFR
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftPiper PA-28R-201T PA-28R-201
Tail NumberN2008M
Aircraft CategoryAir
DamageSubstantial
OperatorRichard Talley/Larry Shattuck
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsContinental · TSIO-360-FB3 · Reciprocating · 200
Seats4

People & Injuries

Injury Summary1 injury (1 minor injury)
Fatal0
Serious0
Minor1
Uninjured0
Total1
Crew 1Age 49 · Third Class

Conditions

ConditionsVMC
LightDaylight
Wind350° @ 4 kt
Visibility30 sm
CeilingBroken clouds 5000 ft
Temperature / Dew Point48 / 34 C
Altimeter30.00 inHg
Observation Time21:50
Weather SourceWFAC

Appendix: Source Data