Skip to content

Atlas / NTSB / CEN18LA065

NTSB CAROL · Event

Event CEN18LA065

2017-12-19 Versailles, Missouri, United States Airport · 3VS None 1 aircraft Status: Completed

Registry · N555WM

FAA Aircraft Registry record.

Make / Model

PIPER PA-28-201T

Year of manufacture

1979 · 38 years old at event

Engine

CONT MOTOR TSIO-360 SER (225 hp)

Seats / Engines

4 seats · 1 engine

Last airworthiness date

19790919

ADS-B equipped

Yes — Mode-S A713FE

Registrant of record

WEST WARREN K

Source: FAA Aircraft Registry (releasable master file).

Aircraft involved

Probable cause & findings

The total loss of engine power due to fuel starvation when the cap fitting came off the inlet tee fitting on the throttle body/fuel metering unit.

Factual narrative

On December 19, 2017, about 1145 central standard time, a Piper PA-28-201T, N555WM, impacted terrain and obstacles during a forced landing after takeoff from the Roy Otten Memorial Airfield (3VS), near Versailles, Missouri. The pilot was not injured; and the airplane sustained substantial damage. The airplane was owned and operated by GPFO LLC under the Title 14 Code of Federal Regulations Part 91 as a maintenance check flight. Visual meteorological conditions prevailed during the flight, which was not operated on a flight plan. The local flight was departing from 3VS at the time of the accident. The pilot stated that an overhauled engine was installed on the airplane and this was the first flight after the engine change. During engine ground operations, no leaks were noted, and the engine operated normally. The pilot accomplished multiple ground runs including a takeoff/abort run. He accomplished the before takeoff checklist and everything was "in the green." The pilot reported that he departed on runway 25, flew once around the airport traffic pattern, and accomplished a touch-and-go. During climbout at 400-500 ft above ground level, a loud bang was heard by a witness on the ground (the pilot did not hear the bang) and the engine lost total power. The pilot conducted a forced landing to a field about 3/4 miles from the airport. During the landing roll, the airplane's left wing a struck metal fence post which resulted in substantial damage. The pilot and the mechanic who performed the engine installation examined the engine at the accident site and noticed a cap fitting was missing from the inlet tee fitting on the throttle body/fuel metering unit. The cap fitting was found between the No. 3 and No. 5 cylinders. After reinstalling the cap fitting, the engine was restarted and ran normally. With the assistance from the local police, the pilot taxied the airplane back to the airport using local roads. The mechanic who installed the overhauled engine stated that the cap fitting was in place when he received the overhauled engine from the repair station. He stated that he had not disturbed the cap fitting during the installation of the engine or during maintenance performed before the maintenance check flight. Although the engine manufacturer recommended that the fuel injection system should be adjusted after an engine installation, the mechanic reported that the engine was operating normally, and he did not perform the maintenance procedures contained in the Continental Motors Service Information Directive SID97-3G. The repair station's quality control manager reported that the fuel system was removed from the engine and overhauled in the component shop. The fuel system, with the cap fitting installed, was tested before it was reinstalled on the engine. Upon completion of the fuel system overhaul and before the engine went to the engine test cell for the final engine run testing, an inspector checked that all the engine fittings were secure. During the engine test run in the test cell, the tee fitting was not used to attach the gauge for the fuel system checks. The quality control manager stated that the cap fitting had not been leaking during the engine runs in the test cell, and that the engine met all the performance objectives without further fuel system adjustments. The private pilot was going to perform a local flight for the first time after an overhauled engine was installed on the airplane. During engine ground operations, no leaks were noted, and the engine operated normally. After takeoff, the pilot flew the airplane around the airport traffic pattern and accomplished a touch-and-go landing. During the climbout, at 400 to 500 ft above ground level, the engine lost total power. The pilot conducted a forced landing to a field. During the landing roll, the airplane's left wing struck a metal fence post, which resulted in substantial damage to the airplane. A postaccident examination revealed that the inlet tee fitting on the throttle body/fuel metering unit was missing a cap fitting, which was subsequently found between the Nos. 3 and 5 cylinders. After the cap fitting was reinstalled, the engine was restarted and ran normally. The mechanic who installed the overhauled engine stated that the cap fitting was in its proper place during the installation of the engine and that he had not disturbed the cap fitting during the maintenance that was performed before the maintenance check flight. The repair station's quality control manager reported that an inspector checked all of the engine fittings to verify that they were secure. During the engine test run, the tee fitting was not disturbed because it was not used to attach the gauge for the fuel system checks, and the engine met all performance objectives of the test run. The engine experienced a total loss of power due to fuel starvation when the cap fitting came off the inlet tee fitting on the throttle body/fuel metering unit. However, the available evidence was not sufficient to determine how the cap fitting became loose and displaced from its installed location. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12

NTSB Findings

Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).

  • C Aircraft-Aircraft systems-Fuel system-Fuel distribution-Damaged/degraded - C
  • C Aircraft-Aircraft systems-Fuel system-Fuel distribution-Incorrect service/maintenance - C

Verbatim from NTSB's published report. Source file NTSB_2017_CEN18LA065.txt. Findings + structured fields enriched from FAA avall.mdb. Full investigation docket on data.ntsb.gov ↗.

Related research

What the literature says.

Academic papers and agency reports matching this event's aircraft type or causal vocabulary (stall, fuel starvation, maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.

Browse the full corpus — academia portal ↗