29 May 2023: PIPER PA-28-181 — CAVORITE AVIATION LLC

29 May 2023: PIPER PA-28-181 (N456Y) — CAVORITE AVIATION LLC

No fatalities • West Jordan, UT, United States

Probable cause

Loss of engine power due to fuel starvation as a result of the mechanic’s failure to properly secure the fuel system gascolator strainer bowl.

— NTSB Determination

Accident narrative

On May 29, 2023, about 1152 mountain daylight time, a Piper PA-28-181, N456Y, was substantially damaged when it was involved in an accident near West Jordan, Utah. The flight instructor and student pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that the local flight from South Valley Regional Airport (U42), Salt Lake City, Utah, was in preparation for the student pilot’s private pilot check ride. He reported that earlier in the morning the aircraft fuel strainer and wing tanks were sumped and were clear of contaminants. A few hours later the airplane was refueled for the accident flight and the airplane was sumped once more. The fuel strainer was clear of contaminants and the right wing had several drops of water visible in the sump tool. The left tank had a significant amount of water visible in the sump tool. The preflight was completed and the engine was started; no anomalies were noted during the startup, taxi, or runup. The flight instructor reported that they departed with the fuel selector on the left-wing tank position. During takeoff, the ground roll was normal, and the airplane departed about 2,000 ft down the runway. About 300 ft agl, the engine started to lose power. The flight instructor took control of the airplane and added full rich mixture and ensured that the throttle lever was at full power. Momentarily, there was an increase in rpm before they lost all engine power. He initiated a forced landing to a soccer field complex about 1/4 mile south of U42. During the landing, the right main landing gear collapsed, and the airplane veered to the right impacting a tree with its right wing. The right wing fuel tank had impact damage and was leaking fuel onsite. Shortly after the accident, the airplane’s wing tanks were defueled from the filler ports, and the airplane was relocated to the airport. About 15 gallons of fuel was collected from the wing tanks. The gascolator and wing tanks were not sumped after the accident or during its relocation back to the airport. A postaccident examination of the wreckage revealed that the gascolator bowl bail wire attachment end was not engaged with the outboard attachment hole on the gascolator housing and was resting on the gascolator bracket forward of the hole, as shown in figure 1. There was no observable impact damage to the gascolator or the surrounding area. The gascolator bowl was not sealed to the gascolator housing and was twisted inboard where the bowl’s sump was pointing forward, instead of its normal position pointing outboard toward the cowling sump access hole. The interior surfaces of both upper and lower cowling were covered in a light residue of oil with the exception of the cowling and firewall area beneath the gascolator.

Figure 1-Gascolator as seen from above.

Figure 2-Gascolator forward side view, lower cowling removed.

The lower engine cowling was removed. The bail wire was not safety wired in place, and the strainer bowl retaining nut was safety wired to the gascolator sump fitting. The strainer bowl retaining nut was not properly positioned on the bottom of the bowl. The gascolator bowl was removed and the seal and screen were undamaged and clear of contamination. The gascolator bowl did not contain any fuel. Review of the maintenance records showed that the last 100-hour inspection was completed on April 1, 2023, about two months before the accident. The airplane had about 3,828 hours of operation at the time of the last inspection and had about 60 hours of operation since that inspection. Both Piper Service Letter 1141, dated April 11, 2011, and the Piper Maintenance Manual provide instructions to maintain and install the gascolator. The instructions direct the installer to safety bail nut and bail wire with MS20995-C32 safety wire, as shown in figure 2. They direct the installer to use the “double twist” method, as described in the latest revision of FAA Advisory Circular (AC) 43.13-1, Chapter 7 (Aircraft Hardware, Control Cables, and Turnbuckles), Section 7 (Safetying).

Figure 3-Excerpt from the Piper Maintenance Manual.

Contributing factors

  • Incorrect service/maintenance
  • Maintenance personnel

Conditions

Weather
VMC, wind 140/09kt, vis 10sm

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