On the morning of the accident, the pilot and two passengers arrived at Northwest Florida Beaches International Airport (KECP) in Panama City, Florida, and the pilot parked the airplane at an FBO ramp about 9:41 a.m.
About 11 a.m., the FBO moved the airplane to another location on the ramp because the pilot and passengers were not returning until later in the day.
A review of the data downloaded from an onboard avionics system revealed that during the flight to KECP, the oil pressure initially stabilized at 89 pounds per square inch (psi) and decreased gradually as oil temperature increased.
Immediately before takeoff power was set, the oil pressure had reduced to about 50 psi. The oil pressure remained steady at 80 psi during the flight. After landing, the oil pressure ranged between 50 and 70 psi (depending on the engine power setting).
A review of security camera video revealed that the pilot returned to the airplane about 3:30 p.m. He opened the baggage compartment, entered and exited the cockpit multiple times, walked around the front of the airplane, and stopped in front of each wing until the two passengers arrived about 3:41. During these 11 minutes, he did not appear to spend any appreciable time inspecting the airplane’s engine or the ground below it.
About 10 minutes later, the airplane exited the FBO ramp and taxied to Runway 34.
The onboard avionics system data showed that immediately after the engine was started, the oil pressure stabilized at about 67 psi. The oil pressure gradually decreased as the oil temperature increased and continued decreasing as the aircraft taxied to the runway.
Immediately before takeoff, the oil pressure had reduced to about 10 psi. When the engine was advanced to takeoff power, the oil pressure dropped to 4 psi.
According to Automatic Dependent System Broadcast (ADS-B) data, the airplane began the takeoff roll about 4:06 p.m. and reached a peak altitude of about 1,200 feet mean sea level (MSL).
According to a summary of air traffic control communications, the pilot declared an emergency at 4:09.
ADS-B data showed the airplane began to descend, made a 180° left turn, and then continued to descend until it hit trees and terrain about 1.7 miles from the runway threshold. The pilot and one of the passengers died in the crash, while the other passenger sustained serious injuries.
The airplane came to rest upright in an area of dense brush at an elevation of 25 feet.
Multiple tree branches located along the debris path exhibited black paint transfer and were cut at 45° angles. Oil was noted along the bottom right side of the fuselage.
Post-accident examination of the engine revealed a breach of the crankcase near the No. 4 cylinder. The engine was disassembled, and continuity of the crankshaft was confirmed. No anomalies were noted on the main journals of the crankshaft.
The No. 4 connecting rod journal exhibited thermal damage, and bearing material was found welded/smeared to the crankshaft journal. The No. 4 connecting rod cap, connecting rod bolts, and bearing pieces were found in the oil sump along with other metallic debris and a trace amount of oil.
The oil drain plug remained seated and safety wired to the oil sump. The oil pump rotated freely by hand. The oil pump was disassembled, and no scoring was noted on the oil pump gears or the housing. The oil pressure sensor was separated from the engine. The sensor’s rigid copper line was fractured at the fitting to the accessory section of the crankcase.
The rigid copper line and oil pressure sensor were examined by the National Transportation Safety Board Materials Laboratory. The examination revealed that most of the fracture occurred on a flat plane perpendicular to the tube axis, and a darker region with a smooth curving boundary was observed at one side identified as the origin area. The remainder of the fracture surface showed a change in fracture plane with dimple features on the fracture surface; those features were consistent with ductile overstress fracture of the remaining ligament of the tube wall.
Post-accident examination of the pavement in the parking area of the FBO revealed a trail of oil drops that led to a small puddle of oil where the airplane was initially parked. A second larger area of oil staining, measuring about 6 feet by 6 feet, was found at the airplane’s second parking location (where the airplane had been moved by FBO personnel), which was where the pilot conducted his walk-around and loaded passengers before he started the engine for taxi and takeoff. Furthermore, there was a trail of oil leading from that spot toward the runway that aligned with the airplane taxiing to the runway.
According to the most recent annual inspection, the Piper PA-28RT-201 had a tachometer time of 508.6 hours. During the annual inspection, a new avionics system was installed, which included a Dynon Skyview HDX panel display and a Dynon electronic flight instrument system.
The airframe maintenance logbook indicated that the work was performed by five people, one of whom was the pilot, and was signed off by a mechanic with inspection authorization.
Additionally, FAA Form 337, Major Repairs and Alterations, indicated that the installation of the Dynon Skyview HDX was performed in accordance with Dynon Skyview HDX System Installation Manual, dated Oct. 28, 2020.
Probable Cause: Maintenance personnel’s failure to follow the avionics installation guidance for the oil pressure sensor, which resulted in the high-cycle fatigue failure of a line, oil starvation, and the subsequent loss of engine power. Contributing to the accident was the pilot’s failure to perform an adequate preflight inspection of the airplane.
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This June 2022 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.
I agree with many contributors on the pilots errors regarding walk around lack of observations, installation errors, preflight, taxiing, and inflight errors. Numerous errors that cost lives and futures needlessly. The aircraft is a tool to get from A to B when in top shape. When not properly maintained an operated it is simply as dangerous as a power saw with loose blade but affects many more people. Fortunately the crash landing was in trees and not an occupied home nor business. I would definitely recommend a drug screen run on pilot post mortem, as there are too many errors here, more then simple stress. My flight training was almost 60 years ago and even though I don’t pilot anymore, I still remember those ingrained rules from the military!
Before every flight your suppose to do a run up (ya it can be done on a long taxi) to check controls and engine. To paraphrase the adage goes ‘flight is not dangerous but any ignorance, carelessness, or neglect’
I fly a piper arrow. Recently After starting the plane I noticed the oil pressure was low checklist after starting check oil pressure. I stopped the engine and added a quart of oil since dip stick showed 6 quarts. I started engine again and taxied. Oil pressure still low,,annunciation light on. I taxied back and mechanic checked oil pump and a small metallic fragment was blocking the pump. Oil filter on cutting open was clear of metallic debris.following the the check list saved me.
From Page 5 of the Dynon System Installation Manual, shown as Docket Item # 10 of the NTSB download, quote ;
10.2.11 Oil Pressure Sensor ……
The pressure sensor has a 1/8-27 NPT pipe thread fitting. ……
Avoid damaging plastic portion of the sensor when threading it into the matching fitting.
Damaging the plastic portion of the sensor may cause sensor failure/leakage and possibly fire.
Unquote
Even though this was not the part that failed, I wonder what the fatigue life for this plastic part is. Evidently longer than, copper foxtrotting tubing ?
Monitor oil pressure? If the oil pressure sending unit was a part of the Dynon Skyview installation, the Skyview Display should have been lit up with caution and warning alarms before take off. How does one simply ignore that?
Moral of the story: “If you see something, say something!”
RIP all.
Regards/J
There are various interpretations of the causes of general aviation accidents. Pilot error is attributed to somewhere between 53 & 88 % depending on who’s stats and opinion are consulted. Couple that with stats of 5 -21 % by mechanical failure and you have a very high probability for problems. Aviation is dangerous, and complacency surely has a fatal element. No further warning is necessary for intelligent and self introspective pilots.
It must be a function of owning, operating and working on aged vehicles and airplanes, but I have a weird habit of going prone and looking for any leakage …
What about the annunciator panel light. If it was operational (has a press to test) it would have been staring the pilot in the face.
Yes, the mechanical failure of a small metallurgical part began this sad accident chain. However, Is a preflight inspection of parts like this by any pilot prioritized very high. Is it practical to remove enough cowling to inspect this part? Time and distractions are a factor. Passengers, fuel loading, weather, ground transport, are also pilot tasks. Maybe there was a lot on the pilot. A Technological Crutch would be Master Caution and system annunciators. Also, impractical for a PA28. Is it good procedure to be scanning engine instruments during the takeoff-roll? NO, It is Not, without a reason- and then after the takeoff has been rejected. I note a lot of discussion on turning back after a loss, full or partial, of thrust on takeoff. Would training “Push!” after loss of thrust- and go straight ahead save lives? Train, memorize, practice procedures, know the systems, always have a plan for each phase of flight and Execute the correct plan.
This wreck and the deaths were not caused by carelessness, neglect, or incompetence.
I suggest scenario based training for pilots, after aircraft handling skills are attained taken in a simulator (best) or fixed position cockpit trainer (easier). The fastest route to major accident/incident prevention. There will always be mechanical, environmental, or other challenges to overcome as pilots.
“Is it good procedure to be scanning engine instruments during the takeoff-roll? NO, It is Not, without a reason- and then after the takeoff has been rejected.” Well it is recommended that the pilot check the instruments after applying takeoff power. “Check the engine instruments for indications of a malfunction during the takeoff roll” (Airplane Flying Handbook pg 6-3).
I agree that the pilot, did not do what needed to be done before and after itinally taxing the aircraft for take off.
However I am asking why didn’t the passengers notice the hugh puddle of oil under the aircraft. Or did they? And not say “anything”? That would seem odd for someone not to say something.
Also the when the ground crew first moved the aircraft they didn’t notice any oil on the ground? It’s possible that they did, but did not attribute oil to that aircraft.
Safety suggests that maybe the ground crew should have at least notified the pilot of a possible oil leak, or at least put a big note on the windshield informing him of this possibility.
Why, take chances? Most times you will get “lucky” once, but alot of times you will not get a second chance in this case the pilot didn’t!
“Experience gives you the test, then teaches you the lesson” that’s if you are willing to learn.
Who doesn’t watch oil pressure and temperature on takeoff and during flight? And the puddle under the engine?
I would think from what I read is that all the occupants neglected to do any observation of the craft and surrounding surface.lm sure they know what preflight procedures are mandatory. I’m wondering if the pilot was in his right mind
I would not expect any passengers to be knowledgeable on any ‘walk-around’ items, unless one was a pilot.
The pilot was doubly responsible not checking the sensor installation, not seeing the low oil pressure and the big puddle on oil on the ground.
Very poor piloting.!!
The oil pressure sensor was incorrectly installed and it looks like the restrictor was not installed.
The pilot apparently did not review the installation vs the Dynon instructions, and the attachment failed in 3 hours.!!
During the flights the pilot looks to have not been monitoring the oil pressure.
His preflight did not check the oil level, otherwise he would have seen a low level.
And, he didn’t note the huge puddle of oil on the ground.!! amazing.!
So, now does the family sue the mechanic , and the insurance co. not pay a claim due to the incorrect installation of the hardware ?
It’s a very sad situation on all counts.!
This is entirely the pilots fault, particularly since he was involved in the faulty installation! He should have done a preflight and noticed the oil pressures in flight and leak on the ground!