CEN25LA053
2024-12-01 · Boscobel, Wisconsin, United States · None · 1 aircraft · Status: Completed
Airport OVS
Current FAA registration · N41997
- Make / Model
- PIPER PA-28R-200
- Year of manufacture
- 1974 · 50 years old at event
- Engine
- LYCOMING I0360 SER (180 hp)
- Seats / Engines
- 4 seats · 1 engine
- Last airworthiness date
- 19740408
- ADS-B equipped
- Yes — Mode-S A4F942
Source: FAA Aircraft Registry (releasable master file).
Aircraft involved
Probable cause & findings
The ice obstruction of the engine oil breather tube and alternate air outlet, which resulted in a failure of the crankcase oil seal and loss of engine oil. Contributing to the accident was the incorrect engine oil breather tube installed in the airplane by maintenance personnel.
Factual narrative
On December 1, 2024, at 1821 central standard time, a Piper PA-28R-200 airplane, N41997, sustained substantial damage when it was involved in an accident near Boscobel, Wisconsin. The flight instructor and pilot receiving instruction were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the flight instructor, they were established in cruise flight on the return leg of a night cross-country instructional flight at 9,000 ft msl, when they noticed an odor in the cockpit. The flight instructor noted no additional issues in the cockpit, and adjusted the cabin heat control, after which the odor diminished. The flight instructor then noticed an opaque windscreen and immediately thought they had encountered icing conditions. The flight instructor contacted ATC and requested a lower altitude. Using a flashlight, the flight instructor illuminated the windscreen and noticed a “brown river” completely obscuring their forward visibility. The cockpit engine oil pressure gauge indicated little to no oil pressure. The flight instructor declared an emergency with ATC and took over control of the airplane from the pilot receiving instruction. The flight instructor located the nearest airport to attempt a forced landing. However, due to restricted visibility due to the oil-covered windscreen, the airplane landed hard adjacent to the runway, bounced, and then came to rest upright on the ground. The airplane sustained substantial damage to the right horizontal stabilator, and the airframe contained engine oil on the top engine cowling, windscreen, and empennage. During recovery of the airplane, recovery personnel noted that the engine oil breather tube and alternate air outlet was obstructed by ice that accumulated during the flight (see Figure 1). Figure 1. Ice-obstructed engine oil breather tube and alternate air outlet. (Source: Myers Aviation - Recovery Company) Additional postaccident examination of the engine revealed that the solid-ring crankshaft oil seal was extruded from the crankcase (see Figure 2). Figure 2. Extruded crankshaft oil seal. According to the airplane manufacturer, Piper Aircraft, Inc., the engine oil breather tube should contain two secondary alternate air outlets that are located within the engine cowling area of the airframe. Additionally, the breather tube primary outlet should not extend beyond 0.5” outside of the engine cowling. The accident airplane’s engine oil breather tube, which was not a Piper Aircraft, Inc. part, contained one alternate air outlet that was fabricated about 1.5” from the end of the breather tube. The end of the breather tube extended about 3” outside of the engine cowling (see Figure 3). Figure 3. Removed breather tube with alternate air outlet and location of engine cowling. A review of the maintenance records revealed that the engine oil breather tube was replaced (part number unknown) on December 18, 2006. No subsequent maintenance entries were noted that referenced any maintenance of the breather tube. During cruise on the return leg of a night cross-country instructional flight at 9,000 ft mean sea level (msl), the flight instructor and student pilot noticed an odor in the cockpit. The flight instructor then noticed an opaque windscreen and immediately thought they had encountered icing conditions. The flight instructor contacted air traffic control (ATC) and requested a lower altitude. Using a flashlight, the flight instructor illuminated the windscreen and noticed a “brown river” completely obscuring their forward visibility. The cockpit engine oil pressure gauge indicated little to no oil pressure. The flight instructor declared an emergency with ATC and assumed control of the airplane from the pilot receiving instruction. The flight instructor located the nearest airport to attempt a forced landing. However, due to restricted visibility due to the oil-covered windscreen, the airplane landed hard adjacent to the runway, bounced, and then came to rest upright on the ground. The airplane sustained substantial damage to the right horizontal stabilator, and the airframe contained engine oil on the top engine cowling, windscreen, and empennage. During recovery of the airplane, recovery personnel noted that ice obstructed the engine oil breather tube and the alternate air outlet. The obstructed breather tube created increased crankcase pressure and caused the extrusion of the solid-ring crankshaft oil seal from the crankcase and subsequent loss of engine oil. Airplane records showed that the oil engine breather tube was replaced about 18 years before the accident. The design, fabrication, and installation of the accident airplane’s oil breather tube did not comply with the airplane manufacturer’s original design criteria. Specifically, the oil breather tube protruded about 3” outside the engine cowling when it should only extend 0.5”. The additional length of oil breather tube outside of the engine cowling would be more susceptible to ice accretion during flight. Additionally, the replaced oil breather tube was not fabricated with alternate air outlets that were positioned within the engine compartment, which would have provided an unobstructed vent after the primary outlet became contaminated with ice during the flight. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
FAA avdata. C = Cause, F = Factor.
- — Environmental issues-Conditions/weather/phenomena-Temp/humidity/pressure-Conducive to structural icing-Effect on equipment
- — Aircraft-Aircraft power plant-Eng oil sys (airframe furnish)-Pressure-Malfunction
- — Personnel issues-Task performance-Maintenance-Installation-Maintenance personnel
Verbatim from NTSB's published report. Source file
NTSB_2024_CEN25LA053.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
Matched on aircraft type or causal vocabulary (icing, stall, maintenance). All research papers
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- arXiv 2023 · arXiv preprint Variation of Critical Crystallization Pressure for the Formation of Square Ice in Graphene Nanocapillaries
Two-dimensional square ice in graphene nanocapillaries at room temperature is a fascinating phenomenon and has been confirmed experimentally.
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The aerospace industry is competing with other industries for a qualified workforce, and many of those competing industries are investing heavily in creating workforce development pipelines.
- arXiv 2022 · arXiv preprint Enhanced Prediction of Three-dimensional Finite Iced Wing Separated Flow Near Stall
Icing on three-dimensional wings causes severe flow separation near stall. Standard improved delayed detached eddy simulation (IDDES) is unable to correctly predict the separating reattaching flow due…
- NASA NTRS 2019 · Contractor Report (CR) An Evaluation of an Analytical Simulation of an Airplane with Tailplane Icing by Comparison to Flight Data
This report presents the assessment of an analytical tool developed as part of the NASA/FAA Tailplane Icing Program. The analytical tool is a specialized simulation program called TAILSM4 which was de…
- NASA NTRS 2019 · Technical Publication (TP) NASA/FAA Tailplane Icing Program: Flight Test Report
This report presents results from research flights that explored the characteristics of an ice-contaminated tailplane using various simulated ice shapes attached to the leading edge of the horizontal …