PA28 Fatal, Panama City, 6/6

Turbo-Arrow-Driver said:
Maybe if the lineman was a pilot, knew how to change frequency on the radio, and knew the tower frequency.
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If the radio is even capable of that. I expect they're using something along the lines of business radios that wouldn't even transmit on an aviation frequency.
 
Looks like prelim is out, see KR for text and photo of oil puddle on ramp. Oil may have drained through hole in crankcase, but that's not entirely clear from the report. Video from FBO shows pilot may have skipped pre-flight inspection of engine/cowling area. Hard to believe that amount of oil on the ground was missed, but it is not clear if this puddle existed prior to engine start.

Edit: the leak could have been from a fractured copper line to the oil pressure sensor, and the hole in the crankcase happened when the #4 cylinder connecting rod bearing locked up and the connecting rod cap broke off...?

KathrynsReport.jpg


http://www.kathrynsreport.com/2022/06/piper-pa-28rt-201-arrow-iv-n160ll-fatal.html
 
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Wow. It certainly appears that amount of oil came from a pressurized source, not just a leak.
 
3393RP said:
Wow. It certainly appears that amount of oil came from a pressurized source, not just a leak.
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If true, there may not have been much (or any) oil on the ground before he started up and taxied away. It’s not always practical to look back at the parking spot.
 
"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 that measured about 6 ft by 6 ft, was found at the 2nd parking location (where the airplane had been moved by the FBO personnel), which was where the pilot conducted his walk-around and loaded passengers before he started the engine for taxi and takeoff."

This is what I find most disturbing in the report.
 
robin ardoin said:
"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 that measured about 6 ft by 6 ft, was found at the 2nd parking location (where the airplane had been moved by the FBO personnel), which was where the pilot conducted his walk-around and loaded passengers before he started the engine for taxi and takeoff."

This is what I find most disturbing in the report.
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Wish we had more...like photos of the drops and the "small puddle". I don't know that particular engine, but with at least four valve covers, 16 pushrod tube O-rings, etc...it's often difficult to keep them entirely leak free (I can attest to this with the Continental TSIO-360 in the Turbo Arrow IV). Without photos or more descriptive text, it's hard to know if the amount of oil in the drops and initial small puddle was enough that it should have caused concern. Also, with the large pool of oil likely destroying the evidence of what existed before engine start it's hard to know what that looked like too.
 
Those drops to the first parking spot could have been very subtle, but enough to catch the investigators attention. However, I can’t imagine the pilot not seeing the larger oil staining and actually inspect the cowling or further, so the blowout after start up seems plausible. I’m giving him the benefit of the doubt. Some ramps have plenty of oil stains, but if it’s same day oil it should look fresh and get the pilots attention. Does the Turbo Arrow have the clamshell cowling for easy inspection, or is it buttoned up with only oil the dipstick and filler door(s)? I have forgotten.
 
TrueCourse said:
Does the Turbo Arrow have the clamshell cowling for easy inspection, or is it buttoned up with only oil the dipstick and filler door(s)? I have forgotten.
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Removing the top cowling half requires undoing about 15-20 half-turn fasteners. Just a door top-center for access to oil filler cap and dipstick. With two valve covers per cylinder, it's a bit more leak prone than some engines.
 
Turbo-Arrow-Driver said:
Removing the top cowling half requires undoing about 15-20 half-turn fasteners. Just a door top-center for access to oil filler cap and dipstick. With two valve covers per cylinder, it's a bit more leak prone than some engines.
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Not so, this airplane had the same cowling as the Archer and most other taper-wing Piper singles. The top half of the cowl is removed simply by four half turn fasteners, then unlatch and lift on the aft portion of the cowl and slide off.
 
RyanB said:
Not so, this airplane had the same cowling as the Archer and most other taper-wing Piper singles. The top half of the cowl is removed simply by four half turn fasteners, then unlatch and lift on the aft portion of the cowl and slide off.
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Yup:
upload_2022-6-21_16-56-16.png
 
RyanB said:
Not so, this airplane had the same cowling as the Archer and most other taper-wing Piper singles. The top half of the cowl is removed simply by four half turn fasteners, then unlatch and lift on the aft portion of the cowl and slide off.
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TrueCourse was asking about the cowl on the Turbo Arrow IV -- not the Arrow IV. The turbo model has a different cowl -- no hump in the middle, and different attachment.
TurboArrowIVcowl.jpg
 
Not a Piper expert but I've only seen Cherokees with the lift up cowling (4 wing nut type - 2 on either side of the cowling).

I've never flown an Arrow, but I have a handful of Archers (-181) and all had the more streamlined cowling. Could only look in the oil check hole (removing the cowling would have been involved, at least as a renter).

1978, 1984 and 2001 models.
 
Oh, I’ve gone done it. Both of you are right. My apologies. The Turbo Arrow was on my mind and I asked about it, also thinking it was the type in this accident. Not so, as it was normally aspirated. Neither NA or Turbo can easily be opened up during routine pre-flight.

Now, that picture of N160LL just posted. That deceptively looks like the basic latch system, lift the cowl up (like a gull wing) to inspect, but not so as was just written.
 
TrueCourse said:
Oh, I’ve gone done it. Both of you are right. My apologies. The Turbo Arrow was on my mind and I asked about it, also thinking it was the type in this accident. Not so, as it was normally aspirated. Neither NA or Turbo can easily be opened up during routine pre-flight.
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The NA PA-28R II/III/IV cowl is about as easy as it gets. As @RyanB highlighted, four strap latches with camlocks, and slide out. Zero tools required. I can pop the top half and place it on the ground clear of the aircraft in under 10 seconds, no exaggeration. Putting it back on takes longer only because you have to align the lip with the lower cowl and sometimes the baffling can interfere, so you gotta fuss and wiggle until seating it clean. Call it 30 seconds to put it back on.

ETA: Based on the pictures, the accident airplane has the same latch system as mine. A 10 second affair to pop that upper cowl open.
 
Are pilots actually taking that cowling off during a preflight for the return leg home on a day trip? A basic Cherokee with the “gull-wing” cowl makes it easy, but as simple as your description is of most Arrow cowls, there is more work involved. Oil dripping is a motivator to take it off, but if no oil dripping is it staying on?
 
FWIW, I don't take the cowl off on an Arrow or Archer, but I always check the oil before every start. If I noticed a pool of oil under the aircraft I'd investigate, but not knowing the area where this plane was, I have no idea if it would be obvious.
 
Albany Tom said:
FWIW, I don't take the cowl off on an Arrow or Archer, but I always check the oil before every start. If I noticed a pool of oil under the aircraft I'd investigate, but not knowing the area where this plane was, I have no idea if it would be obvious.
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Here's a scan of the preflight checklist from the Turbo Arrow IV POH -- just the nose section. Nothing on there requires removing the upper cowling.

One point of note -- there is no alternator belt on the turbo model -- the alternator is mounted to the gear case on the back of the engine and is gear driven through an (unbelievably expensive) slip coupling (to protect the gear train). And yes, I double checked and this is indeed from the POH for the turbo model.

POH-Preflight-003.jpg
 
iamtheari said:
One wonders what the oil pressure indications were from engine start to takeoff.
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"Onboard avionics system data showed that immediately after the engine was started for the accident flight, 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."
 
dmspilot said:
"Onboard avionics system data showed that immediately after the engine was started for the accident flight, 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."
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Thanks. I only got as far as the oil pressure sensor was installed on a rigid line and rattled it apart on the prior flight. It’s hard to imagine a panel recording this data and not making lots of angry noises about it. It seems that a lot of attention-to-detail holes lined up in this particular Swiss cheese sandwich.
 
Not minimizing the lack of pre-flight here, but do any of these engine monitors have an audible alarm for lack of oil pressure? Asking because I've flown aircraft that don't have a stall warning horn, and that is really a non-issue. I think an oil pressure alarm might be handy...although I'm not sure how often that really is the first indication of a problem if a proper pre-flight is done.

Would an oil pressure alarm give you a few extra seconds of warning, or would it typically just go off at the same time you end up with a windscreen covered with oil and it's not providing anything but more noise to an already obvious problem?
 
Albany Tom said:
Would an oil pressure alarm give you a few extra seconds of warning, or would it typically just go off at the same time you end up with a windscreen covered with oil and it's not providing anything but more noise to an already obvious problem?
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If only a few seconds of low oil pressure warnings are given, I agree more noise blasted into the cockpit at that time is not worth the distraction. You're going to find out there's a big problem soon enough from other indications.
 
Albany Tom said:
Not minimizing the lack of pre-flight here, but do any of these engine monitors have an audible alarm for lack of oil pressure?
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Depends on the monitor and how it is installed. All the monitors I am familiar with have on screen alarms with flashing red text. Many have annunciator lights that can be placed in the pilot's line of sight. Some can be connected to your audio system to provide audible warnings.

Caution range for an IO-360 is 60 psi, so he would have been alerted well before takeoff. He only had 3 hours with the new Dynon installed. I'd be willing to bet it was flashing like crazy and he had no idea why.

Multiple layers of pilot incompetence here. Unfortunately in this case it intersected with A&P incompetence, and caught innocent passengers in the bursting radius.
 
Why there aren't plainly visible idiot lights for these basic engine faults like oil pressure, engine temp, fuel in aircraft dumbfounds me.

They've been in every vehicle since the beginning of time where an engine failure won't kill you if you aren't constantly scanning your gages.
 
My dynon gives me an audible "oil pressure" alert every time I shut down.
 
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tobnpr said:
Why there aren't plainly visible idiot lights for these basic engine faults like oil pressure, engine temp, fuel in aircraft dumbfounds me.
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Oil pressure is mechanical in most of them. Same with fuel pressure.
Oil temperature is a resistive sensor, so that could "easily" get an idiot light.
Fuel quantity could also get a low level warning light, but it would need some sort of a delay circuit to remove false alerts from sloshing.
 
iamtheari said:
Thanks. I only got as far as the oil pressure sensor was installed on a rigid line and rattled it apart on the prior flight. It’s hard to imagine a panel recording this data and not making lots of angry noises about it. It seems that a lot of attention-to-detail holes lined up in this particular Swiss cheese sandwich.
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Yeah, it's pretty bad.
"Examination of the rigid oil pressure line revealed that it fractured due to high-cycle fatigue.
This was likely from excessive vibration due to insufficient support of the oil pressure sensor
and rigid line. The oil pressure sensor, which was part of the avionics system, was installed
about 3 flight hours before the accident. The installation manual for the avionics system
stated that a flexible line should be used to install the oil pressure sensor in order to minimize
vibration effects. Instead, a rigid line was installed, which would have been more susceptible to
the effects of vibration, including high-cycle fatigue failure."
Got three hours out if it, anyway. Probably copper tubing laying around the shop, or picked up at Lowe's.
 
tobnpr said:
Why there aren't plainly visible idiot lights for these basic engine faults like oil pressure, engine temp, fuel in aircraft dumbfounds me.

They've been in every vehicle since the beginning of time where an engine failure won't kill you if you aren't constantly scanning your gages.
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Found the guy who didn't start driving until 1990's. :rofl:

No, they haven't been in every vehicle "since the beginning of time". The first car I had which came with oil pressure and temp idiot lights did not have gauges for those. Hence the term "idiot light" because the manufactures decided that people were too stupid to know that you shouldn't continue driving with no oil pressure.

That said, it is relatively simple to add a visual and audible indicator for out of spec functions. And I would guess that most aircraft which use electronic engine monitoring have such indicators.
 
Cold comfort for the relatives I suppose.
 
NealRomeoGolf said:
The owner with oversight from the A&P
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Actually read it... Did they really say 5 different people had signatures in the logbook regarding the install?
 
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