Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Hornbrook, California 96044
Tuesady, October 28, 2003 14:50 PST
NTSB Narrative Summary Released at Completion of Accident
The airplane collided with trees during a forced landing following a loss engine power. Witnesses reported that smoke was trailing from the airplane just before it hit the trees. One witness said that the engine was sputtering, and he heard a couple of "bangs." As the airplane turned to line up with a clear landing area it clipped the tops of some trees and crashed on an embankment adjacent to a dirt road. The owner of a fixed base operator received flight instruction from the certified flight instructor (CFI) in the accident airplane immediately before the accident flight, and noted no mechanical discrepancies. Fifteen minutes later, witnesses watched the airplane takeoff on the accident flight, and reported that the airplane and engine looked and sounded normal. A Federal Aviation Administration (FAA) inspector examined the wreckage on scene and found a significant amount of oil on the right side of the airplane aft of the firewall. The engine separated from the airplane, and came to rest about 15 feet upslope from the wreckage. He noted heavy oil deposits on the bottom cylinders and accessories; the top cylinders were clean. Oil coated the accessory section of the engine. The area around the pre-oil port fitting on the accessory section of the engine was saturated in oil, and the B-nut for that oil line to fitting connection was only finger tight. An examination of the engine revealed damage and thermal distress signatures consistent with an oil starvation catastrophic failure, with no oil present inside the engine. A maintenance logbook entry noted that maintenance technicians had replaced all flexible engine hoses 21 hours prior to the accident.
NTSB Probable Cause Narrative
a catastrophic engine failure from oil exhaustion due to inadequate maintenance installation of the lubricating system hoses.
Event Information
| Type of Event | Accident |
| Event Date | 10/28/2003 |
| Event Day of the Week | Tuesday |
| Time of Event | 1450 |
| Event Time Zone | Pacific Standard Time |
| Event City | Hornbrook |
| Event State | CALIFORNIA |
| Event Country | -- |
| Zipcode of the event site | 96044 |
| Event Date Year | 2003 |
| Event Date Month | 10 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 415203N |
| Event Location Longitude | 1222813W |
| Event Location Airport | -- |
| Event Location Nearest Airport ID | -- |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | -- |
| Degrees magnetic from airport | -- |
| Airport Elevation | -- |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1453 Pacific Standard Time |
| Direction of event from weather observation facility (degrees) | 50 |
| Weather Observation Facility ID | LMT |
| Elevation of weather observation facility | 4095 |
| Distance of event from weather observation facility (units?) | 45 |
| Time Zone of the weather observation | PST |
| Lighting Conditions | Day |
| Lowest Ceiling Height | 3900 |
| Lowest Non-Ceiling Height | 3300 |
| Sky/Lowest/Cloud Conditions | Scattered |
| Sky Condition for Lowest Ceiling | Broken |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 10 |
| Air Temperature at event time (in degrees celsius) | 11 |
| Dew Point at event time (in degress fahrenheit) | 6 |
| Wind Direction (degrees magnetic) | 250 |
| Variable Wind Indicator | Wind direction could be determined |
| Wind Speed (knots) | 13 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | 29.8 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | -- |
| Event Highest Injury | Fatal |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | 1 |
| Injury Total Minor | -- |
| Injury Total None | -- |
| Injury Total Serious | 1 |
| Injury Total All | 2 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 20553 |
| NTSB Notification Source | FAA |
| NTSB Notification Date | Oct 28 2003 12:00AM |
| NTSB Notification Time | 1600 |
| Fiche Number and/or location -used to find docket information | DMS |
| Date of most recent change to record | Oct 31 2006 8:45AM |
| User who most recently changed record | NTSB\JOHB |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | WP-SAC-FSDO |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N28AF |
| NTSB Number | LAX04LA029 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | None |
| Flight plan Was Activated? | No |
| Damage | Destroyed |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | North American |
| Aircraft Model | T-28B |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 138321 |
| Certified Max Gross Weight | -- |
| Aircraft Category | Airplane |
| Aircraft Registration Class | -- |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 2 |
| Number of Engines | 1 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | Conditional |
| Date of Last Inspection | Jan 1 2003 12:00AM |
| Airframe hours since last inspection | 21 |
| Airframe Hours | 15120 |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | No |
| ELT Type | -- |
| Aircraft Owner Name | Ron D. Coffman |
| Aircraft Owner Street Address | -- |
| Aircraft Owner City | Central Point |
| Aircraft Owner State | OR |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 97502 |
| Operator is an individual? | No |
| Operator Name | -- |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | -- |
| Operator City | -- |
| Operator State | -- |
| Operator Country | -- |
| Operator Zip code | -- |
| Operator Code | -- |
| Owner has at least one certificate | None |
| Other Operator of large aircraft? | -- |
| Certified for Part 133 or 137 Operation | -- |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | -- |
| Indicates Domestic or International Flight | -- |
| Operator carrying Pax/Cargo/Mail | -- |
| Type of Flying (Per_Bus / Primary) | Instructional |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | No |
| Departure Airport Code | SIY |
| Departure City | Montague |
| Departure State | CA |
| Departure Country | USA |
| Departure Time | 1430 |
| Departure Time Zone | PST |
| Destination Same as Local Flt | dest & departure same, accident can occur anywhere |
| Destination Airport Code | -- |
| Destination City | -- |
| Destination State | -- |
| Destination Country | -- |
| Specific Phase of Flight | Approach - VFR pattern - final approach |
| Report sent to ICAO? | No |
| Evacuation occurred | No |
| Date of most recent change to record | Aug 22 2006 6:20PM |
| User who most recently changed record | COOS |
| Since inspection or accident | Last Inspection |
| Event Location Runway Number and Location | NA |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |