NTSB CAROL · Event
Event WPR23LA203
Registry · N456Y
FAA Aircraft Registry record.
Make / Model
PIPER PA-28-181
Year of manufacture
2000 · 23 years old at event
Engine
LYCOMING O&VO-360 SER (180 hp)
Seats / Engines
4 seats · 1 engine
Last airworthiness date
20000524
ADS-B equipped
Yes — Mode-S A58A8C
Registrant of record
DODSON INTERNATIONAL PARTS INC
Source: FAA Aircraft Registry (releasable master file).
Aircraft involved
Probable cause & findings
Loss of engine power due to fuel starvation as a result of the mechanic’s failure to properly secure the fuel system gascolator strainer bowl.
Factual narrative
On May 29, 2023, about 1152 mountain daylight time, a Piper PA-28-181, N456Y, was substantially damaged when it was involved in an accident near West Jordan, Utah. The flight instructor and student pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that the local flight from South Valley Regional Airport (U42), Salt Lake City, Utah, was in preparation for the student pilot’s private pilot check ride. He reported that earlier in the morning the aircraft fuel strainer and wing tanks were sumped and were clear of contaminants. A few hours later the airplane was refueled for the accident flight and the airplane was sumped once more. The fuel strainer was clear of contaminants and the right wing had several drops of water visible in the sump tool. The left tank had a significant amount of water visible in the sump tool. The preflight was completed and the engine was started; no anomalies were noted during the startup, taxi, or runup. The flight instructor reported that they departed with the fuel selector on the left-wing tank position. During takeoff, the ground roll was normal, and the airplane departed about 2,000 ft down the runway. About 300 ft agl, the engine started to lose power. The flight instructor took control of the airplane and added full rich mixture and ensured that the throttle lever was at full power. Momentarily, there was an increase in rpm before they lost all engine power. He initiated a forced landing to a soccer field complex about 1/4 mile south of U42. During the landing, the right main landing gear collapsed, and the airplane veered to the right impacting a tree with its right wing. The right wing fuel tank had impact damage and was leaking fuel onsite. Shortly after the accident, the airplane’s wing tanks were defueled from the filler ports, and the airplane was relocated to the airport. About 15 gallons of fuel was collected from the wing tanks. The gascolator and wing tanks were not sumped after the accident or during its relocation back to the airport. A postaccident examination of the wreckage revealed that the gascolator bowl bail wire attachment end was not engaged with the outboard attachment hole on the gascolator housing and was resting on the gascolator bracket forward of the hole, as shown in figure 1. There was no observable impact damage to the gascolator or the surrounding area. The gascolator bowl was not sealed to the gascolator housing and was twisted inboard where the bowl’s sump was pointing forward, instead of its normal position pointing outboard toward the cowling sump access hole. The interior surfaces of both upper and lower cowling were covered in a light residue of oil with the exception of the cowling and firewall area beneath the gascolator. Figure 1-Gascolator as seen from above. Figure 2-Gascolator forward side view, lower cowling removed. The lower engine cowling was removed. The bail wire was not safety wired in place, and the strainer bowl retaining nut was safety wired to the gascolator sump fitting. The strainer bowl retaining nut was not properly positioned on the bottom of the bowl. The gascolator bowl was removed and the seal and screen were undamaged and clear of contamination. The gascolator bowl did not contain any fuel. Review of the maintenance records showed that the last 100-hour inspection was completed on April 1, 2023, about two months before the accident. The airplane had about 3,828 hours of operation at the time of the last inspection and had about 60 hours of operation since that inspection. Both Piper Service Letter 1141, dated April 11, 2011, and the Piper Maintenance Manual provide instructions to maintain and install the gascolator. The instructions direct the installer to safety bail nut and bail wire with MS20995-C32 safety wire, as shown in figure 2. They direct the installer to use the “double twist” method, as described in the latest revision of FAA Advisory Circular (AC) 43.13-1, Chapter 7 (Aircraft Hardware, Control Cables, and Turnbuckles), Section 7 (Safetying). Figure 3-Excerpt from the Piper Maintenance Manual. The flight instructor was conducting a local flight in preparation for the student pilot’s private pilot check ride. The preflight was completed and both wing fuel tanks were filled. The engine was started, and no anomalies were noted during the startup, taxi or runup. During takeoff, the ground roll and departure were normal until the airplane reached about 300 ft above ground level (agl) when the engine started to lose power. The flight instructor took control of the airplane and added full rich mixture and ensured that the throttle lever was at full power. Momentarily, there was increase in rpm before the engine lost all power. He executed a forced landing that caused the landing gear to collapse and damaged the right wing, which resulted in the fuel tank leaking onsite. The postaccident examination revealed that the gascolator bowl bail wire attachment end was not engaged in the outboard attachment hole on the gascolator housing and was resting on the gascolator bracket forward of the hole. There was no observable impact damage to the gascolator or the surrounding area. The gascolator bowl was not sealed to the gascolator housing and was twisted inboard where the bowl’s sump was pointing forward, instead of its normal position pointing outboard towards the cowling sump access hole. The interior surfaces of both upper and lower cowling were covered in a light residue of oil with the exception of the cowling and firewall area beneath the gascolator. The lower engine cowling was removed. The bail wire was not safety wired in place, and the strainer bowl retaining nut was safety wired to the gascolator sump fitting. The strainer bowl retaining nut was not properly positioned on the bottom of the bowl. The gascolator bowl was removed and the seal and screen were undamaged and clear of contamination. The gascolator bowl did not contain any fuel. The gascolator bail wire was not properly attached to the housing and the gascolator bowl likely became unsealed, interrupting the fuel supply to the engine and causing the loss of engine power. 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).
- — Aircraft-Aircraft systems-Fuel system-Fuel filter-strainer-Incorrect service/maintenance
- — Personnel issues-Task performance-Maintenance-(general)-Maintenance personnel
Verbatim from NTSB's published report. Source file
NTSB_2023_WPR23LA203.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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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.
- Embry-Riddle Scholarly Commons 2023 · Conference paper
The Value of Strong Partnerships to Build a Successful Aviation Maintenance Career Pathway Program for Transitioning Military Service Members
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.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA)
From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- NASA NTRS 2026 · Conference Paper
Computational Analysis of Steady State Aerodynamics of Transonic Truss-Braced Wing Configuration in Deep Stall
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- Semantic Scholar 2025 · Article (Applied Sciences)
Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
A New Trajectory in UAV Safety: Leveraging Reinforcement Learning for Distance Maintenance Under Wind Variations
In the field of aviation, safety is a critical cornerstone, and the operation of Unmanned Aerial Vehicle (UAV) systems is deeply connected with this principle.
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