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Pilot forgets to add oil after oil change

By NTSB · September 13, 2016 ·

The Cessna 150 experienced a total loss of engine power during an enroute climb to cruise. The pilot performed a forced landing to a field near Brookfield, Wis., where the plane hit trees and sustained substantial damage.

The pilot stated that he forgot to add engine oil during an oil change he performed on the airplane before the flight.

He said he forgot to add the oil because he was rushed and had personal activities to perform.

Examination of the airplane confirmed engine oil starvation.

A post-accident examination of the airplane revealed no other mechanical anomalies that would have precluded airplane operation.

The pilot held a private pilot certificate and a mechanic certificate with airframe and powerplant ratings.

The NTSB determined the probable cause as the pilot’s inadequate maintenance and preflight of the airplane, which resulted in a total loss of engine power due to oil starvation.

NTSB Identification: CEN14CA515

This September 2014 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.

About NTSB

The National Transportation Safety Board is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation, including railroad, transit, highway, marine, pipeline, and commercial space. It determines the probable causes of accidents and issues safety recommendations aimed at preventing future occurrences.

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Comments

  1. PJ says

    September 14, 2016 at 1:44 pm

    I think it’s interesting that the NTSB report uses the phrase “probable cause” in this case. Ya’ think? All of the symptoms pointed to no oil, but when the pilot admits to forgetting to add the oil, the phrase “probable cause” could replaced with just “cause”. I know it’s standard language and allows for unknowns, but it just seems funny in this case.

  2. Gary K says

    September 14, 2016 at 10:45 am

    Moral of the story: Oil changes are risky, don’t do them:)

    • jay says

      September 14, 2016 at 11:08 am

      I concur not only that they are expensive. That’s why to save money I mix the gas in my airplane like this: 1/4 Avgas, 1/2 mogas and 1/4 water. That water is dirt cheap, so I think I might increase my water input. Also never replace my air filter. When it gets dirty I just throw it away.

      This is obviously all sarcasm, but you never know maybe the owner though that if he didn’t have oil in his airplane he could carry more load in the 150.

  3. Robert says

    September 14, 2016 at 9:31 am

    Recommendations, not always good, but check backround of AP IA , past work AMUST, I’ve delt with 3 + a aero business on my plane airworthiness an all were incompetent, fact one was taken to FAA COURT for frudulent work, an lost his Licence . CARE IS THE WORD

  4. Comanche-Indian says

    September 14, 2016 at 8:13 am

    This was not an oil change, just a drain. How can you forget to replace the old dirty oil with fresh oil? Would you not stumble over the fresh oil cans you prepared for the job before you finished it?

  5. Gordon Gunter says

    September 14, 2016 at 7:14 am

    This falls back onto a proper preflight lets even forget this person has an A & P. If you don’t have time to do a proper preflight you shouldn’t be flying at that time. Even on my busiest days I love to fly because once I am in the plane there is nothing I can do except fly the plane my problems are left on the ground and if it’s to bad and I can’t leave them on the ground then I don’t fly.

  6. John Watts says

    September 14, 2016 at 6:40 am

    He should loose both of his licenses for mistake

    • Randy Coller says

      September 14, 2016 at 7:24 pm

      Agree 100% with your comment John.

    • Eric says

      September 17, 2016 at 11:47 am

      Why should he lose both licenses. He screwed up in his A & E role, which caused him to crash in his pilot role. It’s not the pilot’s fault the mechanic was incompetent.

  7. jay says

    September 14, 2016 at 6:38 am

    When I initially started my experience in aircraft shopping when I would see an ad that said owner is an A&P I would get excited and think to myself “this airplane is solid.” Now after some years of checking out aircraft and being in the industry my opinion is the exact opposite. Most A&P owned aircraft are wrecks, and it seems they hand out A&P ratings to anyone that has a pulse. On top of that most of them don’t even own the basic reading materials of their trade such as AC 43-13-1 and 2 B or an Aviation Mechanic Handbook. That being said there are also amazing A&Ps out there, but in my experience you have to look hard for them.

    With that knowledge this accident report doesn’t surprise me at all, but again is something that could have been prevented provided the pilot (and owner in this case) follow the checklist.

    • John Watts says

      September 14, 2016 at 6:43 am

      U must not be a mechanic cause u just insulted about a million of them

      • jay says

        September 14, 2016 at 7:29 am

        If my harsh words prevent even one fatal accident by ensuring an A&P goes the extra mile to prove me wrong, then I will gladly take the anger from the mechanics.

        I am friends with 2 A&Ps and managed 3 of them in my previous job duties. The ones that I am friends with have a sentiment the same as mine. Of course your experiences and opinions may be different. I am just stating my experiences and opinions.

    • Richard says

      September 14, 2016 at 7:31 am

      Jay, If you think they just hand out mechanic certificates, you should go try to get one. That was really an uncalled for and ignorant comment.

    • John says

      September 14, 2016 at 7:52 am

      Harsh comments, but unfortunately there’s truth in them. Mechanics may or may not be conscientious. They may or may not be competent. Sort of like pilots. If I fly an airplane owned and maintained by an A&P I take the same (and maybe a little more) care with the pre-flight than I would otherwise. I’ve seen mechanics on the shop floor say “it’s good enough”… while short cutting the installation procedures for equipment. I’ve also noticed that some (not all) A&P/AI qualified individuals will inappropriately rely upon their own experience with some critical maintenance issues (like metal in the oil) rather than following published procedures. This seems to be more of a problem with older ones who learned to wrench a long time ago. But I see it with some younger ones. I also know pilots who purchased aircraft from mechanics only to learn that some serious deficiencies weren’t mentioned during the transaction. Caveat emptor applies equally when buying maintenance and when purchasing an annual or special installation. The brush you’re painting with is very broad, but the consequences of misplaced trust are very, very high.

  8. Art says

    September 14, 2016 at 6:36 am

    So what happened to the normal check oil pressure on startup?

    • JimH. says

      September 14, 2016 at 3:11 pm

      Art, I made the same comment below.!! It’s the #1 thing to do after engine start…..look for oil pressure, while setting the throttle to 1,000 rpm, check ammeter for charging. ….then all of the other stuff.

  9. Paul says

    September 14, 2016 at 6:03 am

    What are the two most important fluid volumes to check on an air cooled piston powered airplane? Duh – would that be oil and fuel? Oil dipstick checked on pre-flight?

    • JimH. says

      September 14, 2016 at 8:06 am

      And then immediately after engine start, what do we all look for…
      OIL PRESSURE..!! Every POH has this instruction. If you don’t see oil pressure with 30 seconds, shut the engine off.!!
      It was a Forest Gump moment…. ‘Darwin’ almost got another one.

  10. Tom says

    September 14, 2016 at 5:15 am

    “You gotta know when to hold up, know when to fold up, know when to walk away when the dealing’s done.”

  11. Rod Beck says

    September 13, 2016 at 6:29 pm

    “He FORGOT to add oil?” And an A/P to boot????
    Ok, Ok; He’s 98 an has “frequent” bouts of memory loss – perhaps “Hillary” gave it to him?

    • Richard says

      September 14, 2016 at 7:33 am

      That’s funny. LOL+++++

      • BJS says

        September 14, 2016 at 8:53 am

        Politicians have the worst memories of the population of America. Little wonder the country is in the shape it is

    • Mr X. says

      September 14, 2016 at 8:23 am

      Oh, yea, that was really witty. Right on point, too.
      Sharp as a tack.
      Dave Barry, watch out!

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