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Mechanic’s failure leads to oil starvation

By General Aviation News Staff · June 25, 2025 · 4 Comments

(FAA Photo)

The pilot reported that, during the climb through 4,000 feet mean sea level (MSL), the Piper PA46-350P’s oil temperature began increasing to 215°F, which was higher than the normal range of 190° to 200°F.

He reduced the airplane’s climb rate to increase cooling, but the oil temperature continued to climb to 230°F.

At that time, the pilot requested an instrument clearance back to Easterwood Field Airport (KCLL) in College Station, Texas.

While receiving vectors for the RNAV 11 approach at KCLL, the pilot descended to about 2,000 feet MSL when he noted smoke in the cabin and a loss of engine power.

Unable to glide to any runway, he selected a field to perform a forced landing. The airplane sustained substantial damage to the wings and fuselage during the forced landing.

Eleven days before the accident flight, on June 7, 2023, the pilot was conducting a cross-country flight when he observed decreased manifold pressure and a partial loss of engine power. He diverted to KCLL where, after troubleshooting, a mechanic told the pilot that the turbocharger required replacement.

After the turbocharger was replaced, the mechanic completed an uneventful engine test run.

An engine logbook entry dated June 16, 2023, stated that in addition to replacing the turbocharger, the mechanic drained the engine oil, opened the oil filter, and cleaned the oil pickup screen, where a small amount of metal was observed. The oil sump was flushed, and 11 quarts of new oil added to the engine.

The maintenance logbook entry noted that after the maintenance, the engine ran normally at 42 inches of manifold pressure.

Post-accident examination of the engine was conducted with the assistance of a technical representative from Lycoming Engines. The engine oil sump contained about two quarts of oil, and the recovered oil displayed evidence of metal contamination. The oil filter was removed, and the filter material was found to be saturated with metallic particles.

There was no evidence of any loose or disconnected oil lines.

Engine crankshaft continuity was established with cylinder compression noted on all cylinders except for cylinder No. 6. The spark plugs exhibited signatures of normal operation.

The oil suction screen plug located in the oil sump was found not secured with safety wire as required per the manufacturer’s maintenance manual.

Oil suction screen plug. (Photo Courtesy of Lycoming Engines)

The oil suction screen plug was found loose, with engine oil observed below the oil suction screen plug. The crush washer behind the oil screen plug was found intact with no damage.

A portion of the oil dipstick port and fractured crankcase were submitted for additional metallurgical examination. The laboratory examination revealed no evidence of material defects in the crankcase material, and the observed fracture features were consistent with overload. Additional laboratory analysis of the metallic debris recovered from the oil suction screen was consistent with connecting rod material as well as steel from fittings, fasteners, and brackets.

Probable Cause: The mechanic’s failure to properly secure the oil suction screen plug during recent maintenance, which resulted in an oil leak and subsequent loss of engine power due to oil starvation.

NTSB Identification: 192399

To download the final report. Click here. This will trigger a PDF download to your device.

This June 2023 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.

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Comments

  1. Frank koester says

    June 26, 2025 at 8:27 am

    Well I guess as always Walmart oil and tire for that mechanic.

    Reply
  2. Ted Lang says

    June 26, 2025 at 7:19 am

    I didn’t look up all details of the flight, but i read the text to say the loss of engine power occurred early on the first flight after maintenance, and the strainer/plug was still in place AFTER the crash, though noted to be loose and leaking. I am assuming by the wording that it was still threaded in place, though perhaps the report was just worded poorly. But If the oil level was checked on preflight immediately prior to flight, it seems unlikely that enough oil could have leaked (that fast) around the threads during initial climb, and it would not have threaded itself back in after the event. It would also seem there would have been evidence of a leak on the cowl and/or pavement during preflight. That said, complete thread engagement could easily have been lost LATER in the flight, with the same result of rapid loss of engine oil and power. Thus, it appears that the preflight was incomplete in that it did not confirm oil level, failed to notice significant leakage, or was performed way too long in advance.

    Reply
  3. Fred Burnet says

    June 25, 2025 at 7:23 am

    Wondering if pilot observed any leaks on nose gear or tire. Did he check the oil level before flight. I am a proponent of interactive aircraft repairs. I had my Beach Sundowner Repaired in El Paso, Texas After an Alternator failure. From Fort Stockton, Texas. 3 Months later found the Over voltage Regulator was left loose and failed again in South Carolina.
    Ever since then I made a priority to work along side the AI when aircraft was being worked on. After long flights would remove top cowling and check for leaks of loose or parts. Since this time have had no surprises. Know you airplane inside and out. Learn how systems operate. Will make you better able to diagnose problems in the air, with better outcomes. Flying since the 1970’s many cross country flights from Florida to western destinations.

    Reply
    • JimH in CA says

      June 25, 2025 at 9:50 am

      From the docket, this was the 1st flight after the turbo was replaced. The engine lost most of the oil on the initial climb so he could not have seen the oil loss.

      The screen plug was obviously not torqued besides not being safety wired.
      There was no way that the pilot could have seen that the safety wire was missing during the pre-flight.!

      Reply

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