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Accidents · NTSB WPR14LA345 · Final report

Piper PA 28-236 accident near Salmon, Idaho, August 13, 2014

On August 13, 2014 at about 6:15 pm local time, a 1978 Piper PA 28-236, registered N2190H, was substantially damaged in an accident during enroute (cruise) near Salmon, Idaho (Lemhi County Airport). It was a personal flight under general aviation rules (Part 91). 1 person had minor injuries; 1 other was unhurt. The weather was visual conditions (good weather).

The NTSB's probable cause their words, unchanged

Maintenance personnel’s improper surface preparation of the accessory mount pad for the installation of the engine’s dry vacuum pump, which resulted in the loss of engine oil, oil pressure, and engine power during flight. Contributing to the accident was the lack of a postmaintenance leak check.

Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.

What the record shows

Date
August 13, 2014 · about 6:15 pm local time
Place
Salmon, Idaho · Lemhi County Airport · map
Type
Accident
Injuries
1 person had minor injuries; 1 other was unhurt.
Weather
visual conditions (good weather)
Aircraft
Piper PA 28-236 236, built 1978 · all PA 28-236s on the register
Registration
N2190H · no longer on the register · serial 28-7911060
Damage
Substantial damage
Flight
Personal flight · general aviation rules (Part 91)

The NTSB's narrative final · quoted from the NTSB record

Before departing on the personal cross-country flight, the private pilot noted that there was no engine vacuum indication. He took the airplane to a maintenance facility, and a mechanic replaced the vacuum pump. Following the replacement, no leak check was performed; however, vacuum was restored when the engine was started, and the pilot subsequently departed on the flight. The pilot reported that, about 150 miles from his destination, the engine lost oil pressure. He then turned the airplane toward the nearest airport, and the engine lost power. The airplane was unable to glide to the airport, so he landed it in a hayfield next to the airport. The airplane sustained substantial damage to both wings and the fuselage. During examination of the engine, holes were found in the top of the case. The engine was covered with oily residue, and oil streaking was found along the bottom of the fuselage. The internal engine parts were fragmented, and the oil filter material was infused with metal fragments. During examination of the recently installed "dry" vacuum pump, the appropriate fiber gasket was found in place between the pump body and the accessory mounting pad surface. The gasket appeared intact, and neither side (mating surface) showed signs of tearing or surface scuffing, peeling, or separation. The internal (dry) area was partially filled with oil, and all of the internal parts had oily residue. Oil staining was found on both sides of the gasket and around the accessory pad's pressure crankcase oil passage hole (used for "wet" pump installations), and extended along the internal cavity edge and the exterior perimeter of the pump base on three of its four sides. The pressure crankshaft oil galley hole was not sealed as recommended in the engine manufacturer's service instructions for the installation of a dry vacuum pump. Further, the engine accessory mounting pad was examined, and it had remnants of gasket material not associated with the installed gasket adhered to it, making the surface rough and uneven. It is likely that the new dry pump was installed on an improperly cleaned surface and that this condition, in conjunction with the unsealed galley hole, allowed the engine oil to vent to the exterior of the engine and resulted in the loss of engine oil and oil pressure, internal engine damage, and the subsequent loss of engine power. If a postmaintenance leak check been performed, the oil leaking through the seal or hole would have been detected.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

The factual record from the NTSB's investigation tables, in plain English

What happened, in order

  1. Loss of engine power (total) during enroute (cruise) defining event
  2. Collision with terrain or object (not controlled flight into terrain) during emergency descent

The NTSB's findings

  • cause Aircraft › Aircraft systems › Vacuum system › (general) › Incorrect service/maintenance
  • cause Personnel issues › Task performance › Maintenance › Installation › Maintenance personnel
  • factor Personnel issues › Task performance › Inspection › Post maintenance inspection › Maintenance personnel

Pilot

  • Certificate: private
  • Ratings: single-engine land; instrument: airplane
  • Flight time: 875 hours in all; 815 in this make and model; 13 in the last 90 days; 7 in the last 30 days; 860 as pilot in command
  • Medical certificate: Class 3 (with waivers/limitations)
  • Seat: left
  • Injury: no injuries

The aircraft

  • Airframe total time: 2,772 hours
  • Last inspection: annual inspection, June 26, 2014
  • Maximum gross weight: 3,000 lb
  • Landing gear: fixed
  • Engine: Lycoming IO-540 SER (piston); 0 hours total

The flight

  • Departed from: KGNG Gooding ID at 4:54 pm
  • Destination: S27 Kalispell MT
  • Flight plan: none

Weather at the time

  • Light: daylight
  • Visibility: 10 statute miles
  • Sky: clear
  • Temperature: 64°F (18°C), dew point 57°F (14°C)
  • Altimeter: 30.10 inHg
  • Observation at 5:15 pm from KSMN

Injuries

FatalSeriousMinorNone
Flight crew1
Passengers1

Documents from the investigation the NTSB's docket: the evidence folder behind the report

The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), has not been read from the NTSB for this case yet; the list appears here once it has. Open the docket at the NTSB.

Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.