Inattentive Maintenance Kills Again

A Piper PA-28R-201 crashed in Conway, South Carolina on September 14, 2022, causing fatal injuries to 2.

"Shortly after departure, on the first flight following maintenance, the pilot reported a loss of engine power," reads the NTSB report. "The pilot attempted a forced landing onto a gravel road, but the airplane impacted trees and powerlines on final approach. The airplane came to rest against a berm and a post crash fire ensued."

During their investigation, the NTSB found a good deal of engine damage, oil, and heat discoloration. Following the clues, they believe that the aircraft was returned to service while missing a vital part, despite two pairs of eyes supposedly assuring the work. An A&P had completed work on the Piper Arrow III, and it was signed off on by a director with Inspection Authorization.

"A review of the airplane maintenance records revealed that after a certificated airframe and powerplant mechanic had completed the work on the airplane, the Director of Maintenance, an airframe and powerplant mechanic with inspection authorization, signed off the paperwork to return the airplane back to service. The return to service entry stated that the vacuum pump had been removed but did not address the installation of the drive pad gasket or vacuum pump cover."

The report serves a sobering reminder to double check your work, if nothing else. "In an interview, the mechanic who completed the removal of the vacuum pump and installation of the vacuum pump cover stated that when he removed the vacuum pump, the gasket was still attached to it. He cleaned the mating surface of the cover and drive pad and then installed the cover. He stated that he thought he had replaced the gasket. A review of the work order showed that although the cover had been ordered, there was no record of a gasket being ordered."

FMI: www.ntsb.gov